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I  GUIS   RSCttER,  M.D. 


Columbia  SintoergttpV^ 
in  tfje  Citp  of  J^eto  §9orfe 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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KARL  M,  VOQEL 


NFANT-FEEDING 

IN    ITS    RELATION    TO 

HEALTH  and  DISEASE 

FISCHER 


KARL   M.  VOGEL,  M.  D 

INFANT-FEEDING 


IN  ITS  RELATION  TO 


Health  and  Disease 


LOUIS   FISCHER,  M.D. 

Visiting  Physician  to  the  Willard  Parker  and  Riverside  Huspitals  of  New  York  City;   Attending 

Physician  to  the  Children's  Service  of  the  New  York  German  Poliklinik  ;  Former 

Instructor  in  Diseases  of  Children  at  the  New  York  Post-graduate 

Medical  School  and  Hospital,  etc.,  etc.;  Fellow  of  the 

New  York  Academy  of  Medicine. 


Containing  54   Illustrations,  with   24  Charts  and 
Tables,  Mostly  Original 


TfiURD    BDITIOfl 


Philadelphia 
F.  A.  DAVIS   COMPANY,  PUBLISHERS 

1903 


COPYRIGHT,  1903, 

BY 

F.  A.  DAVIS  COMPANY. 
[Registered  at  Stationers'  Hall,  London,  Eng.] 


Philadelphia,  Pa.,  U.  S.  A.  : 

The  Medical  Bulletin  Printing-house, 

1914-16  Cherry  Street. 


THIS   BOOK 
is 

DEDICATED  TO  MY  FRIEND, 
DR.  GEORGE  F.  SHRADY, 

AS  A 

TOKEN  OF   RESPECT 

FOR  HIS   STERLING  QUALITIES  AS  A  MAN  AND 
HIS  SINCERITY  AS  A  PHYSICIAN. 


PEEFACE  TO  THE  THIKD  EDITION. 


This  book  lias  been  completely  revised;  in  fact, 
almost  entirely  rewritten.  Many  changes  were  deemed 
necessary  to  aid  the  general  practitioner  in  working  for- 
mulas required  for  home-modification  of  milk.  The  author 
has  omitted  the  greater  part  of  the  former  chapter  on 
Gaertner  mother-milk,  inasmuch  as  the  milk  is  not  dis- 
tributed fresh  daily,  which  is  so  vital.  A  new  chapter,  en- 
titled "Milk  Idiosyncrasies  in  Children,"  showing  how  chil- 
dren were  fed  who  could  not  tolerate  milk,  is  added. 

Another  new  chapter,  entitled  "Buttermilk  Feeding," 
treating  of  a  method  of  feeding  in  vogue  in  foundling 
asylums,  has  been  added,  as  has  also  a  chapter  on  "Scurvy." 
The  dietary  for  older  children  has  been  enlarged.  The 
method  of  feeding  in  diphtheria  has  been  rewritten,  and 
the  method  in  use  at  the  Willard  Parker  Hospital  is  de- 
scribed. A  new  chapter  on  "Feeding  Children  Afflicted 
with  Cleft  Palate"  has  been  added. 

A  great  deal  of  attention  has  been  given  to  the  chapter 
on  "Modified  Milk  from  the  Walker-Gordon  Laboratory." 
Much  of  what  had  previously  been  written  on  this  subject 
has  been  left  out.  The  author  believes  that  accuracy  at 
the  laboratory  plus  clean  utensils  is  of  value  in  many 
cases,  and  cites  a  successful  modified-milk  feeding. 

Some  illustrations  showing  specimens  of  "Poor  breast- 
milk"  have  been  added.  In  all,  this  edition  may  safely  be 
trusted  to  aid  those  in  search  of  practical  points  in  modern 
methods  of  breast-  and  bottle-  feeding. 

Louis  Fischek. 
August,  1903. 

(ix) 


PEEFACE  TO  THE  SECOND  EDITION. 


This  book  has  undergone  a  careful  revision.  A  great 
many  chapters  have  been  changed;  some  have  been  added, 
including  a  new  chapter  on  "Infant-feeding  in  Summer 
Complaint."  A  new  diet  for  an  older  child,  after  weaning 
from  the  breast  or  bottle,  has  also  been  added.  It  is  also 
a  gratification  to  the  author  to  note  the  kindly  criticisms 
which  have  appeared  in  the  different,  medical  journals. 
Many  of  the  suggestions  which  have  been  offered  for  im- 
proving the  practical  value  of  the  book  have  been  carefully 
considered,  and  numerous  additions  have  been  made  ac- 
cordingly. 

The  utility  of  this  book  has  been  manifested  by  a  call 
for  a  second  edition  within  six  months. 

Louis  Fischer. 
September  1,  1901. 


(xi) 


PEEFACE  TO  THE  FIEST  EDITION. 


During  ten  years'  experience  in  the  children's  service 
of  one  of  the  largest  children's  clinics  in  this  country  the 
author  has  met  with  many  intricate  problems  in  infant- 
feeding.  Besides  this,  many  points  were  gained,  while 
studying  abroad,  through  the  wise  counsel  of  Professor 
Adolf  Baginsky  at  the  Kaiser  and  Kaiserin  Friedrich  Chil- 
dren's Hospital,  in  Berlin,  both  in  his  hospital  wards  as  well 
as  in  the  out-patient  department. 

While  lecturing  on  diseases  of  children  at  the  New 
York  Post-graduate  School  and  Hospital,  and  later  while 
instructing  at  the  New  York  School  of  Clinical  Medicine, 
the  author  has  noted  the  great  anxiety  with  which  his 
students,  all  of  whom  were  physicians  in  active  practice, 
requested  detailed  information  regarding  the  "Modern 
Methods  of  Infant-feeding." 

•  The  author  has  therefore  felt  that  if  his  experience, 
aided  by  the  suggestions  of  many  good  text-books,  were 
combined  to  give  details  pertaining  to  the  feeding  of  in- 
fants and  children  requiring  breast-feeding  or  hand-feed- 
ing,— so-called  bottle-feeding, — then  his  work  would  serve 
as  a  guide  to  both  the  active  practitioner  and  also  to  the 
beginner  in  medicine. 

Louis  Fischer. 

65  East  Ninetieth  Street, 
New  Yokk  City. 


(xiii)' 


TABLE  OF  CONTENTS. 


PART  I. 

PAGE 
Chapter  I.- — Anatomy     and     Physiology     of     the     Infantile 

Stomach  1 

Chapter  II. — Action     of    Digestive    Ferments     on     Various 

Bacteria  4 

Chapter  III. — Stomach-capacity    6 

Chapter  IV. — Ferments  and  Their  Actions 11 

Chapter  V. — The  Intestinal  Canal  of  the  Infant 15 

Chapter  VI. — Fermentation  and  Absorption  18 

Chapter  VII.— Constituents  of  Milk  25 

Chapter  VIII. — Bacteria  of  the  Intestine 39 

Chapter  IX. — Variations  of  Milk  55 

Chapter  X. — Chemical  Examination  of  Breast-milk 60 

Chapter  XL — Breast-feeding  and  Mixed  Feeding 67 

Chapter  XII. — Wet-nursing  and  Weaning 76 

Chapter  XIII. — Management  of  Woman's  Nipples 89 

Chapter  XIV.— Infant's  Weight   '  92 

Chapter  XV.— Raw  Cows'  Milk 98 

Chapter  XVI. — Constituents  of  Cows'  Milk 107 

Chapter  XVII. — Buttermilk  Feeding  115 

Chapter  XVIII. — Detection  and  Addition  of  Preservatives  to 

Milk    122 

Chapter  XIX.— Cream  and  Modified  Milk  134 

Chapter  XX. — Water  as  an  Infant's  Beverage 142 

Chapter  XXI. — Bottle-feeding,  or  Hand-feeding 144 

Chapter  XXII. — Feeding-table  and  Cream-mixtures 145 

Chapter  XXIII. — Home-modification  of  Milk  148 

Chapter  XXIV.— Sterilized  Milk 169 

Chapter  XXV.— Pasteurized  Milk 177 

Chapter  XXVI.— Tyndallization   183 

Chapter  XXVIL— Nipples  and  Bottles  185 

Chapter  XXVIIL— Dextrinized  Gruels  191 

(XV) 


XVI  TABLE  OF   CONTENTS. 

PART  II. 

PAGE 

Chapter  XXIX. — Feeding  of  Infants  in  Incubators 104 

Chapter  XXX.— Aerated  and  Certified  Milk  204 

Chapter  XXXI.— Infant-foods    206 

Chapter  XXXII.— Milk  Substitutes  218 

Chapter  XXXIII. — Milk  Idiosyncrasies  in  Children 228 

Chapter  XXXIV. — Laboratory  Modification  of  Milk 23G 

Chapter  XXXV. — Forced  Feeding 250 

Chapter  XXXVI. — Feeding  in  Diphtheria-Intubation  Cases.  .   254 

Chapter  XXXVII. — General  Rules  for  Rectal  Feeding 258 

Chapter  XXXVIII.— Feeding  Children  Afflicted  with  Cleft 

Palate  260 

Chapter  XXXIX.— Infant-stools    261 

Chapter  XL. — Nathan  Straus  Milk-laboratories  and  Similar 

Charities    268 

Chapter  XLL— Colic  271 

Chapter  XLII. — Constipation 275 

Chapter  XLIIL— Statistics  286 

Chapter  XLIV— Rachitis    288 

Chapter  XLV. — Scurvy 294 

Chapter  XLVL— Dentition   299 

Chapter  XLVII. — Athrepsia  Infantum  (Marasmus)    303 

Chapter  XL VIII. — Infant-feeding  in  Summer  Complaint  ....   317 

Dietary   321 

List  of  Books  Consulted  346 

Index  348 


PART  L 


CHAPTER  I. 

Introduction. 

In  order  to  understand  the  difference  between  the 
various  forms  of  infant-feeding  it  is  necessary  to  con- 
sider the  anatomy  and  physiology  of  the  very  young 
digestive  tract. 

The  infantile  stomach  is  vertical  and  cylindrical  and 
the  fundus  but  little  developed.  Thus,  whenever  there 
is  a  tendency  to  vomit,  the  antiperistaltic  motions  do 
not  press  against  the  fundus,  but  directly  upward.  There 
is,  therefore,  rather  an  overflow  than  a  vomiting  of  the 
gastric  contents;  this  takes  place  so  easily  that  the  babies 
are'  not  disturbed  by  it.1 

ANATOMY. 

The  muscular  development  is  weakest  at  the  fundus. 
According  to  Fleischmann,  the  oblique  and  the  longi- 
tudinal fibres  described  by  Henle,  which  have  their  origin 
at  the  pyloric  opening,  "do  not  exist  in  the  infant."  The 
investigations  of  Leo  and  von  Puteren  show  that,  in  spite 
of  this  lack  of  muscular  development,  the  stomach  of  a 
nursing  infant  is  emptied  in  one  and  a  half  or  two  hours. 
With  food  that  is  more  difficult  to  digest,  the  gastric  con- 
tents are  propelled  more  slowly. 

The  Mucous  Membrane  of  the  Stomach. — The  mucous 
glands  are  far  more  numerous  on  the  pars  pylorica  than 
in  adults,  whereas  they  are  far  fewer  in  number  at  the 
cardia. 


1  Jacobi,  "Therapeutics  of  Infancy  and  Childhood,"  page  25. 

(1) 


2  INFANT-FEEDING. 

The  mucous  membrane  of  the  infant  secretes  gas- 
tric juice  which,  in  general,  is  similar  in  properties  to 
that  of  the  adult.  The  amount  of  secretion  in  the  infant 
is  far  less  than  in  the  adult,  while  its  chemical  constitu- 
tion is  the  same,  namely:  pepsin,  lab-ferment,  and  acids. 
The  exact  proportion  of  the  ferment  and  pepsin  has  not 
yet  been  studied  sufficiently  to  admit  of  any  positive 
deductions  being  made. 

PHYSIOLOGY. 

It  is  very  important  to  know  that  the  mucous  mem- 
brane of  the  mouth  is  practically  dry  at  birth;  the  secre- 
tion of  saliva  is  very  small,  and,  according  to  Korowin 
and  Zweifel,  increases  toward  the  end  of  the  second 
month. 

The  fermentative  (sugar-forming)  property  of  saliva, 
which  is  trifling  at  the  commencement,  increases  with  the 
quantity  of  the  saliva  secreted.  This  is  essentially  true 
of  other  secretions;  thus,  the  pancreatic  juice  does  not 
have  the  same  emulsifying  properties  in  the  infant  as  in 
adults. 

The  nursing  or  sucking  centre  is  located,  according 
to  experiments  made  on  animals  by  Basch,  in  the  medulla 
oblongata  on  the  inner  side  of  the  corpus  restiforme. 

The  sucking  act  is  reflex;  according  to  Auerbach, 
the  muscles  of  the  tongue  participate  most  actively. 

Acids  in  the  Infant's  Stomach. — The  gastric  contents 
in  a  nursling  contain  two  acids:  (1)  hydrochloric  acid; 
(2)  lactic  acid.  The  relative  acidity  is  smaller  than  in 
adults,  the  highest  point  being  reached  one  and  a  half 
hours  after  nursing.  According  to  von  Puteren,  the 
acidity  is  2  1/2  to  3  times  as  small  as  in  the  stomach  of 
adults.  According  to  Leo,  the  acidity  of  the  gastric  juice 
of  nurslings  1 1/2  hours  after  drinking  is  only  0.13  per 
cent.,  whereas,  in  the  adult,  after  the  same  time,  the 
acidity  is  from  1.5  to  3.2  per  cent.  According  to  Wohl- 
mann,  free  HC1  can  be  found  in  healthy  nurslings  from 


INTRODUCTION".  o 

1  V4  to  2  hours  after  taking  food.  The  percentage  of 
free  HC1  ranges  from  0.83  to  1.8  per  cent. 

Lactic  Acid. — The  quantity  of  lactic  acid  is,  accord- 
ing to  Heubner,  between  0.1  and  0.4  per  cent. 

Pepsin  and  Hydrochloric  Acid. — There  are  two  chief 
functions  of  the  pepsin  and  hydrochloric  acid  which  are 
the  same  in  both  infant  and  adult:  First,  the  power  of 
killing  bacteria:  a  real  bactericidal  power.  Second,  as  a 
solvent  for  albumin.  Thus,  it  is  apparent  that  pathogenic 
micro-organisms  that  might  have  entered  the  stomach  can 
be  destroyed,  although  we  know  the  small  quantity  of 
acid  is  hardly  able  to  cope  with  large  quantities  of  food 
contaminated  with  bacteria. 


CHAPTER  II. 

Action  of  the  Saliva  on  Various  Bacteria. 

Triolo2  describes  a  series  of  interesting  experiments 
with  saliva.  He  first  irrigated  the  mouth  with  bichloride 
or  permanganate  of  potash  solution,  followed  this  by 
irrigation  with  sterilized  water  until  the  disinfecting  sub- 
stances were  removed,  and  then  inoculated  the  surface 
of  various  culture-media  with  the  sputum.  His  results 
proved  that  saliva  possesses  a  distinct  bactericidal  prop- 
erty, for  cultures  of  five-day-old  bacteria  were  destroyed, 
as  well  as  fresh  bacteria  eighteen  hours  old. 

This  property,  however,  was  lost  when  saliva  was 
filtered.  The  saliva  of  the  parotid  and  submaxillary 
glands,  taken  singly,  were  equally  efficacious  as  their 
combined  secretion.  He  believes  that  the  greatest  bac- 
tericidal action  is  due  to  the  secretion  of  the  mucous 
glands  in  the  mouth. 

The  Influence  of  Gastric  Juice  on  Pathogenic 
Germs. 

Gastric  juice  is,  according  to  the  experiments  of  Drs. 
Kurlow  and  Wagner,3  an  exceedingly  strong  germicidal 
agent,  and  when  living  bacilli  get  into  the  intestinal  canal 
it  is  due  to  various  conditions  entirely  independent  of  the 
gastric  juice.  When  the  latter  is  normal  and  in  full  ac- 
tivity, only  the  most  prolific  microbes — such  as  tubercle 
bacilli,  the  bacilli  of  anthrax,  and  perhaps  the  staphylo- 
cocci^-escape  its  destructive  action;  all  others  are  de- 
stroyed in  less  than  half  an  hour.     Similar  influences  exist 


2  Eivista  d'Igiene  e  di  Med.  Prat.,  Neapol. 
sVracht;  Lancet,  March  22,  1890. 

(4) 


INFLUENCE  OF  GASTRIC  JUICE.  5 

in  the  intestines,  as  proved  by  inoculation  with  the  cholera 
bacilli. 

Judging  from  the  results  of  experiments  made  by 
Zagari,  Straus,  and  "Wurtz,  who  exposed  various  patho- 
genic organisms,  among  others  that  of  tuberculosis,  to  the 
action  of  gastric  juice,  we  must  come  to  the  conclusion 
that,  so  long  as  the  gastric  juice  retains  a  sufficient  degree 
of  acidity,  tuberculosis  of  the  alimentary  canal  will  be 
unlikely  to  occur.4 


4  Canadian  Practitioner,  April  1,  1890. 


CHAPTER  III. 

Stomach-capacity. 

At  birth  the  infant's  stomach  has  a  capacity  of  from 
9  to  11  drachms,  or  35  to  43  cubic  centimetres. 

At  the  end  of  1  month  it  is  about  2  ounces,  or  60 
cubic  centimetres. 

At  the  end  of  3  months  the  gastric  capacity  is  about 
4  times  the  amount  at  birth.  This  very  rapid  increase 
from  birth  to  this  time  soon  ceases,  and  the  stomach 
capacity  grows  in  size,  but  at  a  much  slower  rate  of  de- 
velopment.    (Baginsky.) 

The  series  of  experiments  at  the  Children's  Hospital 
at  St.  Petersburg,  made  by  Ssnitkin,  showed  that  the 
weight,  and  not  the  age,  determined  the  capacity  of  the 
stomach,  and  should  be  used  as  a  guide  for  the  quantity 
of  infant-food  required. 

If  the  normal  (initial)  weight  of  an  infant  is  3000 
to  4000  grammes,  or  about  6.6  to  8.8  pounds,  then  1/10o 
part,  plus  the  daily  increase  in  weight  added,  which  nor- 
mally amounts  to  2/3  to  1  ounce,  would  give  the  amount 
of  food  required. 

Biedert  also  regards  the  body-weight  as  an  important 
factor  in  determining  the  amount  of  milk  to  be  given, 
but  Baginsky  argues  that,  while  this  rule  will  hold  good 
for  a  great  many  infants,  he  must  insist  on  relying  upon 
the  scales  to  show  just  how  much  nutriment  has  been 
digested,  and  thus  a  regular  system  of  weighing  plus  the 
inspection  of  the  stools  will  aid  in  establishing  the  quan- 
tity of  food  necessary.  "There  is  no  unanimity  among 
experienced  clinical  observers  upon  the  subject  of  infant- 
feeding."  Thus,  for  example,  while  the  great  majority 
of  clinicians  the  world  over  order  milk  (cows')  in  vary- 
(6) 


STOMACH-CAPACITY.  < 

ing  dilutions,  some  using  the  cereals — like  wheat,  barley, 
rice,  and  farina — to  dilute  and  subdivide  the  curd,  other 
clinical  observers — Budin  and  Variot,  Trench  observers 
— advise  giving  infants  at  birth  whole  milk;  that  is,  pure, 
undiluted  cows'  milk. 

The  following  illustrations  will  serve  to  show  the 
difference  in  the  capacity  of  infants'  stomachs  at  various 
ages,  taken  by  the  author  at  the  morgue  of  Bellevue  Hos- 
pital : — 


Fig.  1. — Infant's  Stomach,  1  Month  Old.  Actual  Size.  From  a 
Case  of  Malnutrition.  Capacity,  about  2  Ounces.  When 
Stomach  was  Filled  it  Held  4  Ounces  Easily.  (Author's 
Collection.) 


INFANT-FEEDING. 


STOMACH-CAPACITY. 


10 


INFANT-FEEDING. 


CHAPTER  IV. 

Ferments  and  Theik  Actions. 

In  newborn  children  the  parotid  alone  contains  ptya- 
lin.  The  diastasic  ferment  seems  to  be  developed  in  the 
submaxillary  gland  and  pancreas  after  two  months  at  the 
earliest.  Hence  it  is  not  advisable  to  give  starchy  foods 
to  infants. 

Ptyalin,  the  diastase  of  the  saliva,  a  hydrolytic  fer- 
ment, or  enzyme,  of  the  group  of  unorganized  ferments, 
acts  only  within  a  certain  range  of  temperature,  being 
most  active  at  about  40°  C.  It  acts  best  in  a  slightly  alka- 
line or  neutral  medium.  Its  action  is  permanently  de- 
stroyed by  boiling. 

Amylopsin,  the  diastasic  ferment  of  the  pancreatic 
juice,  seems  to  be  identical  with  ptyalin,  but  it  acts  much 
more  energetically  on  raw  starch,  as  well  as  upon  boiled 
starch;  at  the  temperature  of  the  body  the  change  is  al- 
most instantaneous.  At  a  low  temperature  this  change 
takes  place  slowly. 

According  to  Musculus,  0' Sullivan,  and  von  Mering, 
ptyalin  and  amylopsin  change  starch  and  glycogen  (ani- 
mal starch)  into  dextrin  and  maltose. 

Erythrodextrin  is  first  formed,  then  achroodextrin, 
and,  from  achroodextrin,  maltose.  At  40°  C.  maltose  is 
slowly  changed  into  dextrose.     (Landois  and  Stirling.) 

Dextrose  and  maltose  turn  the  plane  of  a  ray  of 
polarized  light  to  the  right.  The  general  term  grape- 
sugar  was  used  formerly  to  include  dextrose  (glucose) 
and  maltose. 

The  existence  of  maltose  (though  described  by  Du- 
brunfaut  in   1847)   was  for  a  long  time   doubted  until 

(11) 


12  INFANT-FEEDING. 

O'Sullivan,  in  1872,  confirmed  the  previous  experiments. 
(Foster.) 

In  commerce  the  term  "grape-sugar"  is  applied  to 
the  solid  product  of  the  "grape-sugar  works,"  the  liquid 
product  being  known  as  "glucose." 

Maltose  is  the  end-product  of  the  action  of  malt- 
diastase  on  starch,  and  can  also  be  formed  as  an  inter- 
mediate product  in  the  action  of  dilute  sulphuric  acid 
on  the  same  substance.  It  also  appears  to  be  the  chief 
sugar  formed  from  starch  by  the  diastasic  ferments  con- 
tained in  the  saliva  (ptyalin)  and  pancreatic  juice  (amy- 
lopsin).     (Halliburton.) 

The  diastasic  action  of  succus  entericus,  the  fluid 
of  the  small  intestine,  is  incomparably  weaker  than 
ptyalin  or  amylopsin,  and  seems  only  to  continue  their 
action.  According  to  SchifT,  Busch,  Quincke,  and  Gar- 
land, it  does  not  form  maltose  from  starch  (Eichhorst 
states  that  the  juice  of  the  large  intestine  will  do  this), 
but  changes  maltose,  which  is  usually  the  ulterior  prod- 
uct obtained  by  the  action  of  ptyalin  and  amylopsin, 
into  dextrose.  The  greater  part  of  the  maltose  is  ab- 
sorbed unchanged.  Maltose  and  dextrose  are  both 
crystalline. 

Bourquelot  thinks  that  the  change  from  maltose  to 
dextrose  is  due  to  the  action  of  the  intestinal  schizo- 
mycetes,  and  not  to  the  intestinal  juice  as  such,  the 
saliva,  gastric  juice,  or  invertin.     (Landois  and  Stirling.) 

An  important  property  of  dextrose  is  its  power  of 
undergoing  fermentations.  When  an  aqueous  solution 
of  dextrose  is  submitted  to  the  influence  of  yeast,  alco- 
holic fermentation  results,  yielding  alcohol  and  carbonic 
anhydride.  Lactic  fermentation  occurs  in  the  presence 
of  decomposing  nitrogenous  matter,  especially  of  casein, 
and  is  probably  the  result  of  the  action  of  a  specific 
ferment.  The  first  stage  is  the  production  of  lactic 
acid;  in  the  second,  butyric  acid  is  formed,  with  evolu- 
tion of  hydrogen  and  carbonic  anhydride.     (Foster.) 


FERMENTS    AND   THEIR   ACTIONS.  13 

Glucose  is  easily  fermentable.  (Landois  and  Stir- 
ling.) 

The  glucoses  are  the  only  sugars  capable  of  direct 
fermentation;  of  these,  dextrose  is  more  readily  decom- 
posed by  yeast  than  is  lsevulose. 

Certain  other  sugars  are  capable  of  indirect  fermen- 
tation by  yeast ;  among  these  are  cane-sugar  and  maltose ; 
they  are  first,  however,  hydrolyzed  to  glucose.     (Jago.) 

Sucrose  (cane-sugar)  is  not  readily  absorbed  by  the 
intestinal  mucous  membrane  until  it  has  been  transformed 
into  glucose. 

Glucose  (like  maltose)  is  taken  directly  into  the  cir- 
culation.    (Flint.) 

The  gastric  juice  slowly  changes  cane-sugar  into  glu- 
cose. 

According  to  CI.  Bernard,  invertin  in  the  intestinal 
juice  converts  cane-sugar  into  invert-sugar,  which  is  a 
mixture  of  lsevulose  and  dextrose.  (Landois  and  Stir- 
ling.) 

Dilute  acids  convert  cane-sugar  into  invert-sugar, 
which  consists  of  equal  parts  of  dextrose  and  lsevulose. 

When  subjected  to  the  action  of  ferments,  cane-sugar 
is  first  transformed  into  invert-sugar,  then  into  alcohol 
and  carbonic  acid  (vinous  fermentation).     (Battershall.) 

Succus  entericus  has  been  said  to  change  cane-sugar 
into  grape-sugar  and  by  a  fermentative  action  to  convert 
cane-sugar  into  lactic  acid,  and  this  again  into  butyric 
acid,  with  the  evolution  of  carbonic  acid  and  free  hydro- 
gen.    (Foster.) 

Lsevulose  is  isomeric  with  dextrose,  but  it  turns  the 
plane  of  a  ray  of  polarized  light  to  the  left;  it  is  non- 
cry  stallizable  and  ferments  with  difficulty.  (Landois  and 
Stirling.) 

Lactose,  when  isolated,  is  incapable  of  direct  alcoholic 
fermentation,  but  milk  itself  may  be  fermented.  Lactose, 
however,  is  directly  capable  of  undergoing  lactic  and 
butyric  fermentation.     (Foster.) 


14  INFANT-FEEDING. 

The  theory — which  a  few  years  ago  was  accepted — 
that  carbohydrates,  to  be  absorbed,  must  be  in  the  form 
of  glucose  is  now  known  to  be  wrong. 

Lactose  and  maltose  are  absorbed  without  change,  and 
probably  some  of  the  dextrins.     (Roberts.) 

Lactose  is  a  readily  soluble  and  diffusible  body,  and, 
by  virtue  of  these  properties,  does  not  require  to  undergo 
change  within  the  alimentary  canal  to  be  rendered  fit  for 
absorption.     (Pavy.) 


CHAPTER  V. 

Albumin  and  the  Gastric  Juice. 

Another  property  of  gastric  juice  in  infants  is  the 
transformation  of  albumin  in  the  following  manner:  (1) 
albumose;  (2)  then  peptone;  (3)  and  lastly  syntonin.  It 
is  thus  apparent  that,  although  the  infantile  stomach  plays 
a  subordinate  role  as  a  nourishing  organ,  it  cannot  be 
denied  that  fluid  substances — like  water,  a  solution  of 
salt,  and  solution  of  sugar — are  absorbed,  and  in  a  less 
degree  albumin  also.  The  relative  size  and  capacity  of 
the  stomach  prevent  the  function  from  being  as  thor- 
oughly developed  as  in  the  adult. 

Length  of  Intestine. 

The  relative  length  of  the  intestine  in  nurslings  is 
greater  than  in  adults;  so  that  the  intestine  is  six  times 
as  long  as  the  body.  Torster  believes  this  is  one  reason 
why  nurslings  receive  more  nourishment  from  milk  than 
do  adults.  The  small  intestine  develops  during  the  first 
two  months  of  life  more  than  the  large  intestine,  and  after 
the  second  month  the  reverse  is  true.  The  duodenum 
remains  relatively  the  longer  until  the  end  of  the  fourth 
month.  The  transverse  colon  is  the  widest  and  most  elas- 
tic portion  of  the  large  intestine.  The  continuation  of 
the  large  intestine  in  infants  into  the  rectum  is  indicated 
by  a  narrowing  at  this  point. 

The  relative  length  of  the  large  to  the  small  intestine 
is  stated  by  Trolowsky  to  be,  in  the  newborn,  1  to  6;  in 
nurslings,  1  to  5;    in  adults,  1  to  4. 

Formation  oe  Gas  in  the  Intestine. 

When  we  consider  the  lesser  development  of  the  mus- 
cles of  the  intestine,  we  can  readily  understand  that  peri- 

(15) 


1 6  INFANT-FEEDING. 

staltic  movements  are  more  irregular  and  less  forcible, 
and  that  the  muscles  possess  less  tone;  on  this  account, 
there  is  a  larger  amount  of  gas  contained  in  the  intestine, 
which  constantly  distends  it.  Thus  it  is  apparent  why  the 
abdomen  always  appears  larger  in  the  infant  in  propor- 
tion to  the  other  parts  of  the  body. 

Action  of  Intestinal  Muscles. 

The  action  of  the  intestinal  muscles  is  chiefly  to  trans- 
port the  food  by  a  series  of  peristaltic  movements.  Parts 
of  the  intestine  are  active,  while  others  remain  passive. 
Heubner  maintains  that  post-mortem  examinations  never 
show  all  parts  of  the  intestine  in  the  same  condition,  owing 
to  the  irregularity  of  the  muscular  movement. 

Development  of  Glandular  System. 

The  development  of  the  glandular  system  in  infants 
is  very  poor,  whereas  the  lymphoid  tissues,  follicles,  are 
comparatively  well  developed. 

Lieberkiihn's  glands  are  fewer  in  number  than  in 
adults,  whereas  the  Brunner  glands  in  the  duodenum  are 
numerous  and  well  developed. 

The  Secretory  and  Absorbing  Power  of  the 
Epithelium  and  the  Glands. 

Heubner  maintains  that  the  secretion  takes  place  from 
cells,  located  in  the  small  intestine,  which  are  scattered 
about  and  are  few  in  number,  whereas  in  the  large  intes- 
tine they  are  far  more  numerous. 

Absorption  of  Pat. 

The  absorption  of  fat  takes  place  through  the  intes- 
tinal epithelium  in  the  duodenum  and  jejunum;  the 
glands  also  participate  in  this  action.  According  to  the 
histological  investigations  by  Baginsky,  the  real  absorbing 
system  of  the  intestinal  wall  is  found  in  the  connective- 


ABSORPTION    OF   FAT.  17 

tissue  bodies  of  the  mucous  membrane  of  the  infantile 
intestine,  in  which  are  located  lymphatic  vessels  con- 
nected with  the  larger  lymph-channels  of  the  intestine. 
The  physiological  and  chemical  functions  are  much  less 
developed  in  infante  than  in  adults  because  the  intestinal 
glands  are  relatively  less  developed. 


CHAPTER  VI. 

Liver  and  Bile  in  Nurslings. 

The  liver  in  nurslings  is  relatively  larger  than  in 
adults. 

The  quantity  of  bile  in  the  gall-bladder  is  very  small. 
It  is  of  a  golden-yellow  color,  and  has  a  neutral  reaction. 
Its  specific  gravity  varies  from  1.014  to  1.053.  Accord- 
ing to  Baginsky,  the  bile  in  nurslings  contains  organic 
salts, — cholesterin  and  lecithin, — fat,  and  various  acids 
in  less  proportion  than  in  adults.  Baginsky  was  able  to 
demonstrate  the  presence  of  glycocholic  acid.  The  pres- 
ence of  a  much  less  quantity  of  the  bile-acids  in  the  in- 
fant is  a  beneficial  physiological  condition.  For  it  is 
a  well-known  fact  that  these  acids  inhibit  the  digestive 
action  of  the  pepsin  and  of  the  pancreatic  juice.  An- 
other point  is  that  the  absence  of  a  bile-acid  prevents 
the  assimilation  of  large  quantities  of  fat,  as  it  is  im- 
possible to  split  up  the  fat  into  fatty  acid  and  glycerin. 
Thus,  fermentative  processes  are  much  more  frequent 
in  nurslings  and  appear  with  greater  intensity  than  in 
the  adult,  because  of  the  absence  of  the  biliary  acids. 
The  amylacea  and  all  substances  containing  flour  are — 
owing  to  the  above-described  condition  of  the  pancreatic 
juice  and  the  bile — not  fit  substances  to  give  the  infant, 
especially  during  its  first  three  months  of  life,  although 
very  small  quantities  can  be  digested,  and  after  the  fourth 
month  are  not  only  digested,  but  also  absorbed.  Bagin- 
sky and  Sommerfeld  found  large  quantities  of  mucin  in 
the  bile. 

Unorganized  Ferments. 

The  unorganized  ferments  seem  to  be  nitrogenous 
bodies;    their  exact  composition  is  unknown,  and  it  is 
doubtful  if  they  have  ever  been  obtained  perfectly  pure. 
(Landois  and  Stirling.) 
(18) 


UNORGANIZED    FERMENTS. 


19 


Table  Showing  the  Unorganized  Ferments  Present  in  the 
Body  and  Their  Actions. 


Fluid  or  Tissues. 

Ferment. 

Actions. 

Saliva. 

1.  Ptyalin. 

Converts    starch    chiefly 
into  maltose. 

Gastric  juice. 

1.  Pepsin. 

2.  Milk-curdling. 

3.  Lactic-acid    fer- 

ment. 

4.  Fat-splitting. 

Converts  proteids  into 
peptones  in  an  acid  me- 
dium, certain  by-prod- 
ucts being  formed. 

Curdles  casein  of  milk. 

Splits  up  milk-sugar  into 
lactic  acid. 

Splits  up  fats  into  glyc- 
erin and  fatty  acids. 

Pancreatic  juice. 

1.  Diastasic,  or 

amylopsin. 

2.  Trypsin. 

3.  Emulsive  (?). 

4.  Fat-splitting,  or 

steapsin. 

5.  Milk-curdling. 

Converts  starch  chiefly 
into  maltose. 

Changes  proteids  into  pep- 
tones in  an  alkaline 
medium,  certain  by- 
products being  formed. 

Emulsifies  fats. 

Splits  fats  into  glycerin 
and  fatty  acids. 

Curdles  casein  of  milk. 

Intestinal  juice. 

1.  Diastasic. 

2.  Proteolytic. 

3.  Invertin. 

4.  Milk -curdling. 

Does  not  form  maltose, 
but  maltose  is  changed 
into  glucose. 

Fibrin  into  peptone  (?). 

Changes  cane-sugar  into 
grape-sugar. 

In  small  intestine  (?). 

Blood. 
Chyle. 
Liver  (?). 
Milk. 

Most  tissues. 

Di~stasic  ferments. 

Muscle. 
Urine. 

Pepsin  and  other  fer- 
ments. 

Blood. 

Fibrin-forming  fer- 
ment. 

20  infant-feeding. 

Organized  Ferments. 

Yeast  is  the  type  of  the  living,  or  organized,  fer- 
ments. 

Other  living  ferments,  schizomycetes,  seem  to  be  pro- 
duced from  the  numerous  fungi  introduced  into  the  in- 
testinal canal  with  the  food  and  drink.  (Landois  and 
Stirling.) 

The  action  of  these  organized  ferments  is  now  as- 
cribed to  certain  minute  microscopic  organisms ;  when  the 
result  is  the  production  of  some  useful  body  the  change 
is  termed  "fermentation,"  and  "putrefaction"  when  the 
products  are  useless  and  offensive. 

Briefly  stated,  a  liquid  free  from  ferment-organisms 
or  their  germs  does  not  undergo  fermentation.     (Jago.) 

The  lactic  fermentation  and  putrid  or  butyric  fer- 
mentation of  milk  are  both  due  to  mysteriously  minute 
bacteroid  bodies.     (Blyth.) 

The  fungi  which  occur  everywhere  in  the  atmosphere 
are  the  cause  of  the  spontaneous  acidification  and  subse- 
quent coagulation  of  milk.     (Landois  and  Stirling.) 

The  fermentation  of  carbohydrates,  fats,  and  proteids 
is  believed  to  be  caused  by  these  micro-organisms. 

Each  particular  organism  has  its  special  product  of 
fermentation.     (Jago.) 

Hydrolytic  Agents. 

These  bodies  include  oxalic  and  dilute  hydrochloric 
and  sulphuric  acids. 

Commencing  with  soluble  starch,  these  acids  possess 
the  power  of  converting  the  body  first  into  dextrin  and 
maltose,  and  then  into  glucose. 

The  acid  hydrolytics  also  transform  cane-sugar  into 
glucose. 

There  is  another  most  important  group  of  hydrolyz- 
ing  agents;  these  consist  of  certain  soluble  bodies  of 
organic  origin,  and  among  them  may  be  mentioned  hu- 


ABSORPTION.  21 

man  saliva,  filtered  aqueous  infusion  of  yeast,  flour,  bran, 
and  malt. 

The  following  names  have  been  given  to  active  prin- 
ciples of  these  hydroly tics : — 

Name  of  Hydrolyzing 
Substance.  Constituent. 

Human  saliva.  Ptyalin. 

Yeast.  Zymose,  or  invertin. 

Flour  and  bran,  especially 

the  latter.  Cerealin. 

Malt.  Diastase.     (Jago.) 

Absorption. 

As  most  substances  in  the  state  in  which  they  are 
used  for  food  are  either  insoluble  or  diffuse  but  imper- 
fectly through  membranes,  complicated  digestive  proc- 
esses render  these  substances  soluble  and  diffusible,  and 
thus  fit  them  for  absorption;  most  of  the  fats  are  emul- 
sionized.  The  mucous  membrane  of  the  intestinal  tract 
from  the  cardiac  orifice  of  the  stomach  to  the  anus  is 
adapted  for  absorption.  In  the  stomach,  watery  solutions 
of  salts,  grape-sugar,  maltose,  peptone,  and  poisons,  espe- 
cially alcoholic  solutions  of  poisons,  are  absorbed.  The 
empty  stomach  absorbs  more  rapidly  than  one  filled  with 
food.  Gastric  catarrh  delays  absorption.  The  greatest 
area  of  absorption  is  undoubtedly  the  small  intestine. 
(Landois  and  Stirling.) 

Table  of  the  More  Important  Carbohydrates  and 
Their  Formulae. 

Cellulose    C6H10O5. 

Starch    C6H10O5  or  n(CcH10O5). 

Dextrin    C6H10O5. 

Maltose    C12H22On  or  C12H2Ai  +  H20. 

Dextrose    (glucose,  grape-sugar) C6H12O0  or  C0  +  H12H20. 

Sucrose    (saccharose,  cane-sugar) C12H22Ou. 

Lsevulose  : C6H1206. 

Invert-sugar   C6H120<,. 

Lactose    (milk-sugar)    C12H22On  or  C,2H220„  +  H20. 


22  INFANT-FEEDING. 

The  sugars  are  classified  into  three  groups,  as  given  below,  with 
their  important  members: — 

(A)  Saecharoids   (non-fermentable  sugars) : — 

Mannite  (from  manna) C6H1408. 

Dulcite    C6H14Oa- 

(B)  Glucoses: — 

Dextrose   (grape-sugar,  starch-sugar) C6H12Oa  +  Aq. 

Laevulose  (honey)   CoHujCV 

(C)  Saccharoses: — 

Sucrose   (cane-sugar)    C^H^On  +  Aq. 

Maltose  (malt-sugar)   C^H^Ou  +  Aq. 

Lactose  (milk-sugar)    CJSjaOu  +  Aq. 

Cellulose. 

Cellulose  acts  mainly  as  a  sort  of  connective  tissue 
constituting  the  framework  of  vegetable  organisms. 

Enzymes. 

The  enzymes,  hydrolytic  or  organic  ferments,  act  only 
in  the  presence  of  water;  they  are  most  active  between 
30°  and  35°  C,  and  are  destroyed  by  boiling.  (Landois 
and  Stirling.) 

Hydrolysis. 

The  changes  which  carbohydrates  undergo  have  been 
called  by  the  general  name  of  hydrolysis.     (Jago.) 

Hydrolysis,  when  affected  by  diastase  or  its  congeners, 
is  termed  diastasic  action,  or  diastasis. 

The  ultimate  products  of  diastasis  of  starch  are  sugars 
of  various  kinds;  the  process  of  conversion  is  frequently 
termed  the  saccharification  of  starch. 

Soluble  Starch. 

Researches  of  Brown,  Heron,  and  others  make  it 
probable  that  the  formula  of  starch  is  more  complex 
than  usually  expressed  by  C6H10O5,  and  the  formula 
n(C6H10O5)  is  now  used,  n  expressing  the  unknown. 


ACTION  OF  MALT-DIASTASE.  23 

Soluble  starch  is  expressed  by  the  formula  11(0! 2H20- 

o10). 

Raw  starch  is  insoluble  in  cold  water,  and  cannot  be 
dissolved  by  any  known  liquid  without  change,  it  having 
a  definite  organic  structure,  an  outer  envelope  of  cellulose 
inclosing  the  starch  proper  (amylose,  or  granulose). 

The  cellulose  envelopes  may  be  ruptured  by  mechan- 
ical means  or  by  boiling  in  water;  in  the  latter  case  the 
containing  cellulose  bursts,  from  the  interior  particles 
swelling,  and  the  amylose  dissolves  in  the  water,  forming 
a  viscous  liquid  (gelatinization). 

A  solution  of  starch  (soluble  starch)  is  colorless,  odor- 
less, and  tasteless,  but  is  colored  an  intense  blue  by  the 
addition  of  iodine  in  extremely  small  quantities.     (Jago.) 

Dextrin  is  very  soluble  in  water;  it  can  be  prepared 
from  starch  by  action  of  heat  maintained  at  a  tempera- 
ture of  about  150°  C. 

Starch,  boiled  with  dilute  sulphuric  acid,  will  be  con- 
verted into  dextrin  and  maltose,  and  by  continued  boiling 
most  of  the  dextrin  and  maltose  is  transformed  into  glu- 
cose (dextrose). 

Action  of  Malt-diastase. 

The  action  of  malt-diastase  on  a  solution  of  starch  in 
water  at  temperatures  from  15°  C.  to  about  70°  C.  more 
or  less  rapidly  hydrolyzes  the  starch  into  a  mixture  of  dex- 
trin and  maltose.  The  longer  the  operation  is  continued, 
the  higher  is  the  proportion  of  maltose  produced;  but 
even  prolonged  boiling  does  not  result  in  any  further 
hydrolysis  of  the  maltose  into  glucose. 

Unlike  the  acids,  malt-diastase  is  incapable  of  con- 
verting starch  further  than  into  dextrin  and  maltose. 
(Jago.) 

Brown  and  Heron's  results  lead  to  the  opinion  that 
there  are  several  dextrins.  And  these  dextrins  are  di- 
vided into  two  groups:  erythrodextrins,  those  first  forms; 
and  achroodextrins  (reducing  dextrins).     They  also  think 


24  INFANT-FEEDING. 

that  there  is  an  intermediate  body  between  dextrin  and 
maltose  which  they  call  maltodextrin. 

According  to  Musculus  and  Gruber,  erythrodextrin 
is  a  mixture  of  dextrin  and  soluble  starch. 

Dextrin  does  not  undergo  alcoholic  fermentation ;  but, 
after  dextrose  is  formed  from  it,  the  dextrose  is  capable 
of  directly  undergoing  vinous  fermentation.  (Foster, 
Battershall.) 


CHAPTEK  VII. 

Fat. 

Fat  contained  in  milk  is  no  simple  compound.  It 
consists  of  at  least  nine  compounds.  More  fat  is  found 
in  colostrum,  in  evening  milk,  and  in  the  upper  layers  of 
a  pail  or  bowl  of  milk.  Its  average  percentage  is  4.3  per 
cent.:  a  great  deal  more  than  in  human  milk.  For  this 
reason  Jacobi5  has  always  taught  that  "it  is  better  to 
reduce  the  fat  to  be  given  to  infants  than  to  increase  it." 

The  deficiency  of  butter  does,  however,  seriously  im- 
pair the  nutritive  value  of  the  milk. 

When  there  is  not  enough  butter  in  the  milk  the 
casein  present  is  digested  with  more  difficulty,  and  the 
result  is  the  same  as  if  the  casein  were  in  excess. 

The  plastic  (building)  materials  of  food  cannot  be 
converted  into  the  tissues  of  the  body  without  the  pres- 
ence of  fat.  Fat  seems  to  be  essential  to  the  formation 
of  new  cells,  whose  nucleoli  always  contain  fat,  and  there 
is  more  in  young  and  rapidly  growing  tissues  than  in  those 
whose  growth  has  been  slackened  by  maturity.  From  this 
is  evident  the  immense  importance  of  fat  in  the  nutrition 
of  the  rapidly  growing  infant-body. 

Sugar. 

The  effects  when  the  amount  of  sugar  is  insufficient 
will  be  partly  the  same  as  when  butter  is  deficient,  for 
the  reason  that  sugar  partly  supplies  the  place  of  butter 
and  partly  is  converted  into  fat. 

Other  substances  that  result  from  the  decomposition 
of  sugar  are  of  importance  in  many  ways.     Lactic  acid  is 


5  A.   Jacobi,   "Intestinal   Diseases   of   Infancy   and    Childhood," 
page  87. 

(25) 


2G  INFANT-FEEDING. 

formed  in  the  stomach,  helps  to  give  acidity  to  the  gastric 
juice,  and  thus  assists  in  the  digestion  of  casein. 

Milk  in  which  sugar  is  deficient  frequently  becomes 
a  source  of  constipation  in  the  child.     (Jacobi.) 

Carbohydrates. 

This  name  is  given  to  a  class  of  compounds  contain- 
ing six,  or  some  multiple  of  six,  atoms  of  carbon  united 
with  hydrogen  and  oxygen,  the  latter  two  in  the  same 
proportion  as  in  water,  H20;  for  illustration,  the  carbo- 
hydrate, starch,  is  expressed  by  (06H1005)n  (simplest  for- 
mula). 

Hydrocarbons. 

Numerous  compounds  of  carbon  with  hydrogen  are 
classed  under  the  general  name  of  hydrocarbons;  the 
generic  formula  CnH2n  +  2  is  applied  to  such  hydrocar- 
bons as  petroleum,  marsh-gas,  and  oils  formed  by  the  dry 
distillation  of  coal,  wood,  etc.  (turpentine,  etc.). 

Fats. 

In  chemical  constitution  fats  consist  of  the  ethers  of 
the  higher  fatty  acids. 

Butyrin,  or  butter-fat,  has  the  formula  C2H5(C4- 
H702)3. 

Lard  contains  palmitin  [C3H5(C16H3102)3]  and 
stearin  [08HB(C18H35C2)3]. 

Castor-oil  contains  ricinolein  [CsB^CigHssOa^]  and 
palmitin  (as  above). 

The  constitution  of  many  fats  and  fixed  oils  is  unde- 
termined. 

Another  source  of  fat  is  its  formation  from  albu- 
minous bodies.     (Landois  and  Stirling.) 

"While  nitrogenous  matter  is  mainly  devoted  to  tissue- 
formation,  the  non-nitrogenous  alimentary  principles — 
the  fats  and  the  carbohydrates — supply  the  source  of 
power, — are  appropriated  to  force-productions. 


FATS.  27 

The  term  "hydrocarbons"  has  been  applied  by  many 
writers  to  fats. 

The  fats  are  a  class  by  themselves.  The  hydrocar- 
bons are  marsh-gas,  benzin  and  its  homologues,  and  re- 
semble the  fats  in  many  ways,  but  exhibit  decided  pecul- 
iarities, which  mark  them  as  a  distinct  group. 

The  fats  have  the  general  formula  of  C10H18O. 

Fats  are  easily  oxidized,  yielding  heat  chiefly,  and 
belong,  therefore,  to  the  calorifacient  group. 

There  is  every  reason  to  believe,  however,  that  fat 
is  essential  to  tissue-development,  as  it  seems  to  be  in- 
trinsically mixed  up  with  nitrogenized  matter  in  the  ani- 
mal tissues. 

Though  fats  cannot,  per  se,  supply  what  is  required 
for  tissue-development,  they,  nevertheless,  take  part  in 
the  process.     (Pavy.) 

Fat  is  absorbed  in  the  form  of  an  emulsion  produced 
by  the  action  of  the  bile  and  pancreatic  juice;  the  villi 
of  the  small  intestine  are  the  chief  absorbents,  but  the 
epithelium  of  the  stomach  and  that  of  the  large  intestine 
also  take  a  part.     (Landois  and  Stirling.) 

The  fats  and  the  carbohydrates  seem  to  be  quite 
closely  allied. 

Part  of  the  fat  of  the  body  is  derived  directly  from 
the  fat  of  the  food,  and  it  is  absorbed  and  deposited  in 
the  tissues. 

According  to  Y.  Yoit,  no  fat  is  formed  in  the  body 
directly  from  carbohydrates. 

Lawes  and  Gilbert,  Heiden  and  V.  Wolff  arrived  at 
the  conclusion  that  the  carbohydrates  absorbed  are  di- 
rectly concerned  in  the  formation  of  fats.  "We  must  as- 
sume that  the  carbohydrates  are  consumed  or  oxidized  in 
the  body  and  that  thereby  a  non-nitrogenous  body  derived 
from  the  proteids  is  prevented  from  being  burned  up,  and 
that  it  is  changed  into  fat  and  stored  up  as  such.  ISTo 
doubt,  fat  is  formed  indirectly  in  the  blood  in  this  way. 
(Landois  and  Stirling.) 


28  INFANT-FEEDING. 

The  balance  of  evidence  seems  to  be  in  favor  of  the 
view  that  carbohydrates  may  be  in  some  way  directly  con- 
verted into  fat. 

The  characteristic  feature  of  proteid  food  is  that  it 
increases  the  oxidative,  metabolic  activity  of  the  tissues, 
leading  to  a  rapid  consumption,  not  only  of  itself,  but  of 
non-nitrogenous  food  as  well. 

One  value  of  fats  and  carbohydrates  lies  in  their  being 
sources  of  energy,  more  than  three-quarters  of  the  normal 
income  of  potential  energy  coming  from  them;  they  are 
ultimate  sources  of  muscular  energy  as  well  as  of  heat. 
Their  great  characteristic  is,  however,  that  they  do  not, 
like  proteid  food,  excite  the  metabolic  activity  of  the 
body,  and,  therefore,  instead  of  giving  rise  to  bodies 
demanding  immediate  excretion  from  the  system,  they 
can  deposit  their  metabolic  products  as  apparently  little 
altered,  but  in  reality  greatly  changed,  fat.     (Foster.) 

Chloride  of  Sodium  (Table-salt). 

If  the  chlorides  in  the  blood  produce  hydrochloric 
acid,  then  their  necessity  is  apparent.  All  infants  should, 
therefore,  receive  a  sufficient  quantity  of  table-salt  with 
each  feeding.  Brucke  states  that  salt  is  transformed  by 
electrolysis  into  hydrochloric  acid.6 

Salts. 

The  several  saline  matters,  including  the  extractives 
of  animal  and  vegetable  food,  are  no  less  essential  ele- 
ments of  a  diet  than  proteids,  fats,  or  carbohydrates,  by 
reason  of  their  regulating  the  energy  of  foodstuffs,  more 
strictly  called.  They  are  necessary  to  life;  the  body  in 
their  absence  fails  to  carry  out  its  usual  metabolism,  and 
disease,  if  not  death,  follows. 


6  Hammersten,    "Physiological    Chemistry    of   Digestion,"    page 
185,  first  edition. 


SALTS  AND   WATER.  29 

The  salts  must  have  important  functions  in  directing 
the  metabolism  of  the  body.  The  striking  distribution  of 
them  in  the  tissues,  the  preponderance  of  sodium  chlo- 
rides in  blood-serum  and  of  potassium  phosphates  in  the 
red  corpuscles,  must  have  some  meaning,  though  we  are 
in  the  dark  concerning  it. 

Salts  and  Water. 

The  element  phosphorus  seems  no  less  important  than 
carbon  or  nitrogen;  the  element,  sulphur,  again,  is  only 
second  to  phosphorus,  and  is  a  constituent  of  nearly  all 
proteids. 

We  know  that  the  various  saline  matters  are  essen- 
tial to  health;  that  when  they  are  not  present  in  proper 
proportions  nutrition  is  affected;  that  the  properties  and 
reaction  of  various  proteid  substances  are  closely  depend- 
ent on  the  presence  of  certain  salts;  but  beyond  this  we 
know  very  little. 

Last,  water  has  an  effect  on  metabolism,  as  shown  by 
the  fact  that,  when  the  water  of  a  diet  is  increased,  the 
urea  is  augmented  to  an  extent  beyond  that  which  can  be 
explained  by  the  increase  of  fluid  augmenting  the  facili- 
ties of  mere  excretion.     (Foster.) 

Albuminous,  or  Proteid,  Substances. 

The  proteids  form  a  large  group  of  closely  related 
substances,  all  of  which  are,  perhaps,  modifications  of  the 
same  body.  The  infant  manufactures  most  of  the  pro- 
teids of  its  ever-growing  body  from  the  casein  of  milk. 
Their  chemical  constitution  is  quite  unknowm.  Some  are 
soluble,  others  insoluble,  in  water.  The  most  important 
nitrogenized  principles  used  as  food  are  musculin,  albu- 
min, casein,  fibrin,  gelatin,  and  gluten.  The  product  of 
the  digestion  of  such  principles  in  the  stomach  was  called, 
by  Mialhe,  albuminose;  afterward,  by  Lehmann,  pep- 
tones.    This  change  renders  them  not  easily  coagulable 


30  INFANT-FEEDING. 

and  endosmotic,  so  that  they  pass  through  membranes 
with  facility  and  are  readily  assimilated  after  their  ab- 
sorption.    (Flint.) 

Nitrogenous  alimentary  matter  may  be  said  to  serve 
principally  for  the  development  and  renovation  of  the 
living  tissues. 

As  to  the  production  of  a  fat  as  a  result  of  the  split- 
ting up  of  nitrogenous  matter,  it  is  highly  probable  that 
such  production  takes  place,  but  anything  in  the  nature 
of  proof  of  this  is  wanting. 

The  nitrogenous  compounds  are  mainly  "histoge- 
netic,"  or  tissue-forming,  materials,  but,  by  the  sepa- 
ration of  urea  which  occurs  in  their  metamorphosis  in 
the  animal  system,  an  hydrocarbonaceous  compound  is 
left,  which  may  be  appropriated  to  heat-production. 
(Pavy.) 

The  nitrogenous  bodies  of  milk  are  not  thoroughly 
understood,  and  are  too  frequently  classed  under  one 
head :    proteids. 

For  about  five  days  after  calving  colostrum  is  secreted 
by  the  mammary  glands.  This  colostrum  is  poor  in  fat 
and  sugar,  but  rich  in  proteids,  which  vary  between  15 
and  20  per  cent.  These  proteid  bodies  are  not  well  un- 
derstood, but  albumin  is  about  two-thirds  of  the  total 
quantity.  Casein  is  also  present.  Colostrum  is  curdled 
by  rennet,  but  not  as  easily  as  milk.  It  is  interesting 
to  note  here  that,  for  commercial  purposes,  the  stomach 
of  a  calf  under  four  days  old  is  practically  worthless  for 
furnishing  rennet.  It  is  well  known  that  large  quantities 
of  albumin  are  absorbed  without  peptonization;  so  it 
would  be  seen  that  Nature  intended  to  furnish  a  very 
digestible  food  for  the  first  few  days  of  life.  By  the  fifth 
or  sixth  day  normal  milk  is  secreted,  the  change  from 
colostrum  to  milk  being  gradual,  the  quantity  of  albumin 
decreasing  until  in  the  normal  milk  it  runs  about  0.4  per 
cent.  "When  the  secretion  ceases  to  coagulate  on  boiling, 
it  is  considered  milk. 


PROTEIDS.  31 


Proteids. 


The  division,  by  Baginsky,  of  the  various  component 
parts  of  milk  into  fat,  carbohydrate,  albumin,  casein,  salts, 
and  water  gives  a  clearer  insight  into  the  vital  necessities 
of  a  growing  infant.  We  have  adopted  this  division  from 
a  clinical  standpoint,  because  frequently  a  chemical  re- 
port of  an  examination  of  breast-milk  will  show  "deficient 
proteids,"  and  hardly  convey  to  the  unskilled  which  vital 
element  is  lacking. 

If,  however,  deficient  albumin  and  casein  were  noted, 
instead  of  combining  the  two  as  one  element  and 
calling  them  proteids,  then  raw  albumin,  as  the  white 
of  egg  or  yolk  of  egg,  would  suggest  themselves  to 
remedy  the  element  found  wanting.  I  shall,  there- 
fore, speak  of  "deficient  albuminoids"  and  "deficiency  in 
casein"  rather  than  combine  these  elements  under  the 
one  heading  of  proteids,  which  is  now  being  used  by  so 
many  text-books. 

A  Clinical  Method  for  the  Estimation  of 
Beeast-milk  Proteids.7 

"Two  'milk-burettes,'  each  containing  5  cubic  centi- 
metres of  milk,  are  subjected  to  a  temperature  warm 
enough  rapidly  to  sour  the  milk,  and  are  allowed  to  re- 
main in  this  warmth  until  a  distinct  precipitation  can  be 
seen.  The  burettes  are  then  cooled  in  water,  the  milk- 
serum  is  withdrawn  into  the  graduated  tubes,  10  cubic 
centimetres  of  Esbach's  solution  (picric  acid,  5  grammes; 
citric  acid,  10  grammes;  water,  500  cubic  centimetres) 
are  added,  the  tubes  are  shaken  and  centrifugated  until 
constant  reading,  and  the  resulting  precipitate  is  read. 
This  reading  expresses  in  percentage  the  amount  of  total 
proteids  in  the  milk. 


7  Reprinted  in  large  part  from  George  Woodward's  article  in  the 
Philadelphia  Medical  Journal,  May  21,  1898. 


32  INFANT-FEEDING. 

"Such  is  a  bare  statement  of  the  method.  I  will 
briefly  take  up  the  various  steps  in  detail.  The  'milk- 
burettes'  are  made  of  about  10  cubic  centimetres'  capacity, 
and  have  a  glass  pinch-cock  or  valve  and  a  narrow  exit- 
tube  about  one  inch  long  (Fig.  8).  I  have  tried  various 
forms  of  burettes  and  separating  funnels,  and  find  this 
the  most  satisfactory.  A  temperature  of  from  95°  F.  to 
100°  F.  is  the  most  rapidly  effective  to  produce  fermen- 
tation. This  I  have  conveniently  obtained  by  placing  the 
tubes  in  a  burette-stand  and  the  stand  in  contact  with  a 
radiator.  The  time  required  to  obtain  a  distinct  precipi- 
tation of  casein  is  from  eighteen  to  twenty-four  hours. 


Fig.  8. — Woodward's  Burette  for  Estimating  Proteids. 


At  the  end  of  this  time  the  milk  has  distinctly  separated 
into  an  upper  layer  of  viscid  yellow  fat;  a  lower  layer 
of  fluid  milk,  quite  opaque  above,  almost  translucent  be- 
low; and,  clinging  to  the  sides  of  the  tube,  and  especially 
at  the  bottom,  a  granular  precipitate.  The  cooling  of  the 
milk  increases  the  viscidity  of  the  fat  and  facilitates  its 
separation  from  the  milk-serum.  The  milk-serum  is  re- 
ceived into  15-cubic-centimetre  graduated  tubes,  the  solu- 
tion of  picric  and  citric  acids  added  up  to  the  15-cubic- 
centimetre  mark,  the  mixture  stirred  with  a  glass  rod  and 
placed  in  the  hand-centrifuge.  The  amount  of  centrifuga- 
tion  required  is  in  direct  proportion  to  the  care  used  in 
separating  the  fat.     If  fermentation  be  watched  and  the 


LIME-SALTS  IN  COWS'  MILK.  33 

separation  be  made  as  soon  as  the  casein-precipitate  is  dis- 
tinctly present,  the  centrifngation  to  a  constant  reading 
may  be  quickly  accomplished." 

Lime-salts  in  Cows'  Milk. 

Milk  curdles  under  two  entirely  distinct  sets  of  con- 
ditions: (1)  it  curdles  on  addition  of  an  acid  and  (2)  it 
curdles  under  the  influence  of  rennet  (when  the  reaction 
of  the  milk  is  either  neutral  or  slightly  acid).  The  two 
varieties  of  curd  which  are  obtained  under  these  circum- 
stances may  be  denominated  "acid  curds"  and  "rennet 
curds/'  respectively.  Acid  curds  must  inevitably  be 
formed  in  the  stomach  after  milk  has  been  drunk,  if  the 
gastric  contents  are  allowed  to  become  acid.  Such  curds 
(we  are  familiar  with  them  in  ordinary  life  in  the  form, 
for  instance,  of  cream  cheese  or  sour  milk)  are  probably 
not  sufficiently  firm  to  set  up  digestive  disturbances.  On 
the  other  hand,  rennet  curds  (such  as  we  are  familiar 
with  in  the  form  of  renneted  milk  and  of  ordinary  cheese) 
may  be  extremely  firm.  It  is,  therefore,  in  all  probability 
these  rennet  curds  which  set  up  the  familiar  infantile 
dyspepsia  of  bottle-fed  children.  If  this  is  so,  the  facts 
elicited  by  Arthus  and  Pages  would  appear  to  be  of  domi- 
nating importance  in  the  treatment  of  these  dyspeptic 
conditions.  In  order  to  appreciate  this  correctly  the  fol- 
lowing facts  must  be  attended  to:  (1)  rennet-coagulation 
is  delayed  and  curdling  becomes  less  and  less  firm  as 
an  increasing  proportion  of  the  lime-salts  of  the  milk 
becomes  precipitated  as  insoluble  salts  (Arthus  and 
Pages) ;  (2)  addition  of  soluble  lime-salts  (up  to  a  certain 
maximum)  causes  increased  rapidity  of  rennet-coagula- 
tion, accompanied  by  increased  firmness  of  clot  (Arthus 
and  Pages);  (3)  human  milk  contains  0.03  per  cent,  of 
lime  (Bunge);  (4)  cows'  milk  contains  0.17  per  cent,  of 
lime  (Bunge).     (Lancet.) 


34  infant-feeding. 

Lime-water  and  Milk. 

Dr.  Brunn8  finds  the  use  of  lime-water  as  an  addition 
to  milk  a  frequent  cause  of  constipation  and  consequent 
fissures  of  the  anus  in  children.  Any  cause  which  pro- 
duces diarrhoea,  with  following  constipation,  will  cause  it. 
Constipation,  proctitis,  and  severe  pains  on  defecation  are 
the  results  of  a  fissure.  Hernia  and  masturbation  are 
possible  consequences.  The  condition  may  be  long-last- 
ing, although  it  is  easily  discovered  when  attention  is 
called  to  it.  He  treats  it  by  regulating  the  diet,  by  clean- 
liness, irrigation  of  the  rectum,  and  by  dilation  of  the 
sphincter  ani,  which  is  easily  done. 

Bicarbonate  of  Soda  in  Milk. 

The  addition  of  the  bicarbonate  of  soda  to  milk  for 
its  preservation  has  hitherto  been  tolerated  by  the  police, 
but  the  Council  of  Hygiene  of  the  Seine  has  condemned 
the  practice,  as  it  is  not  free  from  danger.  The  trans- 
formation of  the  sugar  of  milk  into  lactic  acid  gives  rise, 
in  milk  so  adulterated,  to  a  lactate  of  soda,  which  is  purga- 
tive, and  is  thus  a  cause  of  diarrhoea  in  young  children. 
Under  these  conditions  the  Council  considers  that  the 
addition  of  the  bicarbonate  of  soda  to  milk,  which  is  an 
aliment  of  the  first  order  and  very  often  prescribed  for 
invalids  and  children,  should  neither  be  authorized  nor 
tolerated.9 

Soda  is  also  added  to  milk  sometimes  to  delay  the 
souring  process.  The  prohibition  of  this  chemical  may  be 
viewed  in  the  light  of  a  stultification  when  we  consider 
the  large  amount  of  bicarbonate  of  soda  that  is  used  at 
the  present  day  in  one  of  the  popular  methods  of  feeding 


8  Hospitals-tidende,  R.   3,  B.  8,  S.  1089;   Medical  and  Surgical 
Reporter,  February  13,  1892,  page  277. 

8 Lancet  (London),  February  11,  1888. 


MILK-SUGAR.  35 

infants.     I  think  it  is  no  less  reprehensible  on  the  part 
of  the  physician  than  it  is  on  the  part  of  the  dairyman.10 

Milk-sugar. 

Process  of  Making.  —  The  milk  is  collected  and  al- 
lowed to  stand  for  several  hours  in  cooling  vats;  then  it 
is  conveyed  to  a  large  tank,  to  be  coagulated.  Various 
substances  are  used  to  hasten  the  coagulation.  According 
to  Flint,11  vinegar,  cream  of  tartar,  muriatic  acid,  and 
sour  milk  can  be  used  to  produce  coagulation,  but,  of 
course,  rennet  is  the  most  popular  and  most  commonly 
used  agent.  This,  as  we  all  know,  is  the  fourth  stomach 
of  the  calf.  The  directions  given  for  preparing  rennet 
are  as  follow:  "Care  must  be  taken  not  to  use  too  much 
water  in  cleaning;  wiping  lightly  with  a  moistened  cloth 
until  it  is  clean  is  the  better  way.  If  then  blown  up  like 
a  bladder  and  hung  up  and  dried,  it  will  retain  its  power 
for  coagulating  milk  for  years."  Pieces  of  this  rennet  are 
steeped  in  warm  water,  and  the  solution  from  it  is  added 
to  the  milk  and  then  the  milk  is  raised  to  a  temperature 
above  100°  and  kept  at  that  until  coagulation  takes  place. 
Then  the  whey  is  drawn  off,  and  this  whey  is  evaporated 
by  boiling  to  one-fifteenth  of  its  original  mass.  This 
is  dipped  out  into  a  tub,  where  the  sugar  will  crystallize 
in  twenty-four  to  forty-eight  hours.  These  crystals  are 
known  as  "sand" ;  this  sand  is  put  into  sacks,  from  which 
the  water  drains  off.  The  sand  is  again  boiled  in  water 
to  a  sufficient  concentration,  and  the  sugar  is  allowed  to 
crystallize  in  sticks.  It  will  thus  be  seen  that  many  of 
the  other  crystallizable  bodies  contained  in  milk  would  be 
included  in  this  crystallization,  as  well  as  the  alkaloids 
or  ptomaines. 


10  E.  E.  Brush,  M.D.,  in  the  Journal  of  the  Amei-ican  Medical 
Association,  November  23,  1889. 

11  "Milk-cows  and  Dairy-farming." 


36  INFANT-FEEDING. 

The  use  of  milk-sugar  has  increased  notably  during 
the  last  few  years,  in  the  feeding  of  children,  through  the 
recommendations  of  Soxhlet  and  Reubner.  It  is  not  gen- 
erally known,  however,  that  under  some  circumstances  the 
milk-sugar  of  cheaper  sorts  may  be  contaminated  by  the 
presence  of  bacteria,  derived  from  the  milk  from  which 
it  is  made.  In  repeated  examinations  the  author  has 
found  a  large  number  of  bacteria,  and  among  them  those 
which  lead  to  the  formation  of  gas:  a  form  particularly 
feared  because  of  its  power  to  decompose  milk.  If  such 
milk-sugar  be  added  to  sterilized  milk  it  quickly  curdles 
it;  if,  also,  a  small  quantity  of  such  sugar  be  added  to  a 
sterile  milk,  and  subjected  to  the  usual  sterilizing  methods 
for  twenty  or  even  forty  minutes  it  is  not  as  certainly 
rendered  free  from  germs  as  is  the  case  with  ordinary 
milk.  Enough  germs,  however,  are  destroyed  so  that  the 
milk  will  not  spoil  until  the  second  or  third  day.  With 
the  Soxhlet  method  of  preparing  the  milk  it  was  found 
that  a  very  impure  milk-sugar  could  be  used  without 
harm,  provided  the  milk  was  used  up  within  twenty-four 
hours.  It  was  quite  another  matter  when,  as  the  author 
found,  certain  venders  of  sterilized  milk  added  the  pow- 
dered sugar  after  the  sterilization  process.  Through  the 
addition  of  the  impure  milk-sugar,  countless  germs  were 
introduced  into  the  sterile  milk,  and,  since  the  milk  is 
only  slightly  warmed  before  feeding,  they  enter  the  ali- 
mentary canal  of  the  child,  where  they  may  produce  the 
very  evils  one  has  sought  to  avoid.  Under  such  circum- 
stances the  use  of  the  relatively  sterile  beet-  or  cane-  sugar 
is  preferable.  From  this  is  derived  the  practical  rule  that 
cheap  grades  of  milk-sugar  should  be  avoided  in  the  prep- 
aration of  the  food  of  infants,  or  at  least  that  they  should 
be  used  only  before  a  careful  sterilization  of  the  milk. 
(H.  Neumann.12) 


12  Berliner  klinische   Wochenschrift;    American   Medico-Surgical 
Bulletin. 


MILK-SUGAR.  37 

Dr.  E.  E.  Brush,13  of  Mount  Vernon,  K  Y.,  says  that 
"one  of  the  faults  of  physiological  chemists  is  that  they 
make  no  distinction  between  a  substance  existing  in  a 
natural  condition  and  that  substance  eliminated  and  iso- 
lated by  chemical  means.  Thus,  the  sugar  of  milk  of 
commerce  and  the  sugar  of  milk  as  it  exists  in  that  fluid 
are  regarded  by  the  chemists  as  one  and  the  same  thing. 
Hence,  the  physician  has  been  led  into  the  error  of  think- 
ing that  as  the  sugar  in  milk  is  that  designed  by  nature 
as  the  best  saccharine  nutrient,  therefore  the  isolated 
sugar  must  fulfill  the  same  function.  This  is  not  the 
truth.  Sugar  of  milk  in  that  fluid  is  all  assimilated,  and 
the  milk-sugar  of  commerce,  when  added  to  baby  food,  is 
eliminated  both  by  the  kidneys  and  bowels.  This  I  have 
demonstrated  by  numerous  experiments.  I  have  never 
found  sugar  present  in  the  urine  or  fseces  of  babies  fed  at 
the  breast.  On  the  other  hand,  in  three  cases  of  infants 
fed  in  twenty-four  hours  with  3  ounces  or  more  of  mix- 
tures containing  commercial  milk-sugar  (as  in  Meig's 
mixture),  I  have  always  found  sugar  in  the  urine  and 
fasces,  demonstrated  by  Fehling's  test." 

Impurities  in  Milk-sugar. — J.  O.  Braithwaite14  states 
that  the  new  United  States  Pharmacopoeia  methods  of 
testing  milk-sugar  do  not  suffice,  because  they  consider 
only  the  contents  in  grape-sugar  and  cane-sugar.  He 
found  in  a  great  number  of  samples  a  disproportionately 
high  residue  of  ash,  which  coagulates  milk  when  the  latter 
is  heated  to  nearly  the  boiling-point.  This  is  a  serious 
defect,  since  milk-sugar  serves  now  mainly  as  a  material 
for  preparing  artificial  food  for  infants.  The  author 
found  the  ash,  in  several  samples,  to  consist  chiefly  of 
magnesium;  he  found  lime  in  one  sample;  and  concludes 
that,  during  the  preparation  of  the  sugar,  magnesium 
carbonate  and  lime  had  been  used  for  neutralizing  the 


13  Journal  of  the  American  Medical  Association,  July  5,  1890. 

14  London  Pharm.  Journal,  April  14,  1894. 


38  INFANT-FEEDING. 

acid  solution,  and  that,  during  crystallization,  magnesium 
lactate  had  crystallized  out  with  the  milk-sugar.  The 
author  confirmed,  by  way  of  experiments,  the  well-known 
fact  that  many  metallic  and  earthy  salts  coagulate  milk, 
and  that  magnesium  lactate  does  so  also,  even  in  milk- 
sugar  to  which  0.5  per  cent,  of  the  salt  had  been  admixed. 
He  suggests  that  the  pharmacopoeias  restrict  the  amount 
of  ash  from  milk-sugar  to  0.25  per  cent,  as  a  maximum. 
Bacteria  in  Milk-sugar.  —  Prof.  Albert  R.  Leeds15 
states  that  all  the  samples  of  pulverized  milk-sugar  com- 
ing from'  drug-stores  and  which  he  had  examined  gave  an 
abundant  crop  of  bacteria  when  definite  weights  dissolved 
in  sterilized  water  were  submitted  to  ordinary  gelatin- 
peptone  culture;  and  the  presence  of  bacteria  as  a  com- 
mon impurity  in  lactose,  to  be  looked  for  and  avoided 
by  the  chemist  and  the  druggist,  was  sufficiently  demon- 
strated. 


15  Journal   of  the  American  Chemical   Society;    Oil,  Paint,  and 
Drug  Reporter,  August  31,  189G. 


CHAPTER  Yin. 

Bacteria  of  the  Intestine. 

There  are  a  great  many  bacteria  found  in  the  intes- 
tine. These  are  present  in  a  normal  infant,  as  well  as  in 
an  infant  suffering  from  a  gastro-intestinal  disorder.  A 
great  many  of  these  bacteria  are,  therefore,  non-patho- 
genic. Miller,  who  carefully  studied  the  various  micro- 
organisms in  the  mouth,  found  that  most  of  them  could 
again  be  found  in  the  intestinal  canal.  He  also  found 
that  certain  germs  possessed  diastasic  properties,  and  were 
capable  of  producing  lactic-acid  fermentation  in  the  milk- 
fseces  of  nurslings. 

Escherich  found  two  germs,  the  one  he  called  "bac- 
terium lactis  aerogenes  (or  bacterium  aceticum,  Bagin- 
sky)"  and  the  other  the  bacterium  coli  commune.  In  the 
meconium  he  found  proteus  vulgaris,  streptococcus  coli 
gracilis,  and  bacillus  subtilis. 

bacterium  coli  commune  (escherich). 

Obtained  by  Emmerich  (1885)  from  the  blood,  vari- 
ous organs,  and  the  alvine  discharges  of  cholera  patients 
at  Naples;  by  Weisser  (1886)  from  normal  and  abnormal 
human  faeces,  from  the  air,  and  from  putrefying  infu- 
sions; by  Escherich  (1886)  from  the  fasces  of  healthy 
children;  since  shown  to  be  constantly  present  in  the 
alvine  discharges  of  healthy  men,  and  probably  of  many 
of  the  lower  animals.  Eound  by  the  author  in  the  blood 
and  various  organs  of  yellow-fever  cadavers  in  Havana 
(1888  and  1889). 

Numerous  varieties  have  been  cultivated  by  different 
bacteriologists,  which  vary  in  pathogenic  power  and  to 
some   extent  in  their  growth  in  various   culture-media; 

(39) 


40  INFANT-FEEDING. 

but  the  differences  described  are  not  sufficiently  charac- 
teristic or  constant  to  justify  us  in  considering  them  as 
distinct  species. 

Morphology.— Differs  considerably  in  its  morphology 
as  obtained  from  different  sources  and  in  various  culture- 
media.  The  typical  form  is  that  of  short  rods  with 
rounded  ends;  from  two  to  three  microns  in  length  and 
0.4  to  0.6  micron  broad;  but  under  certain  circumstances 


Fig.  9. — Bacterium  Coli  Cummune. 

the  length  does  not  exceed  the  breadth — about  0.5  micron 
— and  it  might  be  mistaken  for  a  micrococcus;  again  the 
prevailing  form  in  a  culture  is  a  short  oval;  filaments  of 
five  microns  or  more  in  length  are  often  observed  in  cul- 
tures, associated  with  short  rods  or  oval  cells.  The  bacilli 
are  frequently  united  in  pairs.  The  presence  of  spores 
has  not  been  demonstrated.  In  unfavorable  culture- 
media  the  bacilli,  in  stained  preparations,  may  present 
unstained  places,  which  are  supposed  by  Escherich  to  be 
due  to  degenerative  changes  in  the  protoplasm.     Under 


BACTEJRIUM    COLI    COMMUNE.  41 

certain  circumstances  some  of  the  rods  in  a  pure  culture 
have  been  observed  by  Escherich  to  present  spherical, 
unstained  portions  at  one  or  both  extremities,  which 
closely  resemble  spores,  but  which  he  was  not  able  to 
stain  by  the  methods  usually  employed  for  staining  spores, 
and  which  he  is  inclined  to  regard  as  "involution  forms." 

The  bacillus  stains  readily  with  the  aniline  colors 
usually  employed  by  bacteriologists,  but  quickly  parts 
with  its  color  when  treated  with  iodine  solution — Gram's 
method — or  with  diluted  alcohol. 

Biological  Characters.  —  An  aerobic  and  facultative 
anaerobic,  non-liquefying  bacillus.  Sometimes  exhibits 
independent  movements,  which  are  not  very  active.  One 
rod  of  a  pair,  in  a  hanging-drop  culture,  may  advance 
slowly  with  a  to-and-fro  movement,  while  the  other  fol- 
lows as  if  attached  to  it  by  an  invisible  band  (Escherich). 
The  writer's  personal  observations  lead  him  to  believe 
that,  as  a  rule,  this  bacillus  does  not  exhibit  independent 
movements.  Does  not  form  spores.  Grows  in  various 
culture-media  at  the  room-temperature — more  rapidly  in 
the  incubating  oven.    Grows  in  a  decidedly  acid  medium. 

In  gelatin  plates  colonies  are  developed  in  from 
twenty-four  to  forty-eight  hours,  which  vary  considerably 
in  their  appearance  according  to  their  age,  and  in  differ- 
ent cultures  in  the  same  medium.  The  deep  colonies  are 
usually  spherical  and  at  first  are  transparent,  homogene- 
ous, and  of  a  pale-straw  or  amber  color  by  transmitted 
light;  later  they  frequently  have  a  dark-brown,  opaque 
central  portion  surrounded  by  a  more  transparent  periph- 
eral zone;  or  they  may  be  coarsely  granular  and  opaque; 
sometimes  they  have  a  long-oval  or  "whetstone"  form. 
The  superficial  colonies  differ  still  more  in  appearance; 
very  young  colonies  by  transmitted  light  often  resemble 
little  drops  of  water  or  fragments  of  broken  glass;  when 
they  have  sufficient  space  for  their  development  they 
quickly  increase  in  size,  and  may  attain  a  diameter  of 
three  to  four  centimetres;   the  central  portion  is  thickest, 


42  INFANT-FETCDTNG. 

and  is  often  marked  by  a  spherical  nucleus  of  a  dark- 
brown  color  when  the  colony  has  started  below  the  surface 
of  the  gelatin;  the  margins  are  thin  and  transparent,  the 
thickness  gradually  increasing  toward  the  centre,  as  does 
also  the  color,  which  by  transmitted  light  varies  from 
light-straw  color  or  amber  to  a  dark  brown.  The  outlines 
of  superficial  colonies  are  more  or  less  irregular,  and  the 
surface  may  be  marked  by  ridges,  fissures,  or  concentric 
rings,  or  it  may  be  granular.  The  writer  has  observed 
colonies  resembling  a  rosette,  or  a  daisy  with  expanded 
petals.  Escherich  speaks  of  colonies  which  present  star- 
shaped  figures  surrounded  by  concentric  rings. 

In  gelatin  stick  cultures  the  growth  upon  the  surface 
is  rather  dry,  and  may  be  quite  thin,  extending  over  the 
entire  surface  of  the  gelatin,  or  it  may  be  thicker,  with 
irregular,  leaf-like  outlines  and  with  superficial  incrusta- 
tions or  concentric  annular  markings.  An  abundant  de- 
velopment occurs  all  along  the  line  of  puncture,  which, 
in  the  deeper  portion  of  the  gelatin,  is  made  up  of  more 
or  less  closely  crowded  colonies ;  these  are  white  by  re- 
flected light,  and  of  an  amber  or  light-brown  color  by 
transmitted  light;  later  they  may  become  granular  and 
opaque.  Frequently  a  diffused  cloudy  appearance  is  ob- 
served near  the  surface  of  the  gelatin,  and  under  certain 
circumstances  branching,  moss-like  tufts  develop  at  in- 
tervals along  the  line  of  growth.  One  or  more  gas-bubbles 
may  often  be  seen  in  recent  stick  cultures  in  gelatin. 

Upon  nutrient  agar  and  blood-serum,  in  the  incu- 
bating oven,  an  abundant,  soft,  shining  layer  of  a  brown- 
ish-yellow color  is  developed.  The  growth  upon  potato 
differs  considerably,  according  to  the  age  of  the  potato. 
According  to  Escherich,  upon  old  potatoes  there  may  be 
no  growth,  or  it  may  be  scanty  and  of  a  white  color.  In 
milk  at  37°  C,  an  acid  reaction  and  coagulation  of  the 
casein  are  produced  at  the  end  of  eight  or  ten  days.  In 
the  absence  of  oxygen  this  bacillus  is  able  to  grow  in  solu- 
tions containing  grape-sugar  (Escherich).     In  bouillon  it 


BACTERIUM    COLI    COMMUNE.  43 

grows  rapidly,  producing  a  milky  opacity  of  the  culture- 
liquid.  The  thermal  death-point  of  Emmerich's  bacillus, 
and  of  the  colon  bacillus  from  faeces,  was  found  by  Weis- 
ser  to  be  60°  C,  the  time  of  exposure  being  ten  minutes. 
The  author  has  obtained  corresponding  results.  Weisser 
found  that  when  the  bacilli  from  a  bouillon  culture  were 
dried  upon  thin  glass  covers  they  failed  to  grow  after 
twenty-four  hours.  These  results  give  confirmation  to 
the  view  that  the  bacillus  under  consideration  does  not 
form  spores. 

Pathogenesis.  —  Comparatively  small  amounts  of  a 
pure  culture  of  the  colon  bacillus  injected  into  the  cir- 
culation of  a  guinea-pig  usually  cause  the  death  of  the 
animal  in  from  one  to  three  days,  and  the  bacillus  is  found 
in  considerable  numbers  in  its  blood.  But,  when  injected 
subcutaneously  or  into  the  peritoneal  cavity  of  rabbits  or 
guinea-pigs,  a  fatal  termination  depends  largely  on  the 
quantity  injected;  and,  although  the  bacillus  may  be  ob- 
tained in  cultures  from  the  blood  and  the  parenchyma  of 
the  various  organs,  it  is  not  present  in  large  numbers,  and 
death  appears  to  be  due  to  toxaemia  rather  than  to  septi- 
caemia. Mice  are  not  susceptible  to  infection  by  subcu- 
taneous injection.  Small  quantities  injected  underneath 
the  skin  of  guinea-pigs  usually  produce  a  local  abscess 
only;  larger  amounts — two  to  five  cubic  centimetres — 
frequently  produce  a  fatal  result,  with  symptoms  and  path- 
ological appearances  corresponding  with  those  resulting 
from  intravenous  injection.  These  are  fever,  developed 
soon  after  the  injection,  diarrhcea,  and  symptoms  of  col- 
lapse appearing  shortly  before  death.  At  the  autopsy  the 
liver  and  spleen  appear  normal,  or  nearly  so;  the  kidneys 
are  congested  and  may  present  scattered  punctiform  ec- 
chymoses  (Weisser).  According  to  Escherich,  the  spleen 
is  often  somewhat  enlarged.  The  small  intestine  is  hyper- 
asmic,  especially  in  its  upper  portion,  and  the  peritoneal 
layer  presents  a  rosy  color;  the  mucous  membrane  gives 
evidence  of  more  or  less  intense  catarrhal  inflammation, 


44  INFANT-FEEDING. 

and  contains  mucus,  often  slightly  mixed  with  blood.  In 
rabbits  death  occurs  at  a  somewhat  later  date,  and  diar- 
rhoea is  a  common  symptom.  In  dogs  the  subcutaneous 
injection  of  a  considerable  quantity  of  a  pure  culture  may 
give  rise  to  an  extensive  local  abscess. 

Varieties. — Booker,  in  his  extended  studies  relating 
to  the  bacteria  present  in  the  fasces  of  infants  suffering 
from  summer  diarrhoea,  has  isolated  seven  varieties  "which 
closely  resemble  bacterium  coli  commune  in  morphology 
and  growth  in  agar,  neutral  gelatin,  and  potato,  but  by 
means  of  other  tests  a  distinction  can  be  made  between 
them."     These  are  described  as  follows: — 

BACILLUS    "d"    OF    BOOKER. 

"Found  in  two  cases  of  cholera  infantum  and  the 
predominating  form  in  one  serious  case  of  catarrhal  en- 
teritis. 

"Morphology. — Resembles  bacterium  coli  commune. 

"Growth  in  Colonies. — Gelatin:  Colonies  grow  lux- 
uriantly in  gelatin,  and  thrive  in  acid  and  sugar  gelatin 
equally  as  well  as  in  neutral  gelatin.  In  the  latter  the 
colonies  closely  resemble,  but  are  not  identical  with,  the 
bacterium  coli  commune.  In  acid  gelatin  they  differ  very 
much  from  bacterium  coli  commune.  The  colonies  spread 
extensively,  and  are  bluish  white,  with  concentric  rings. 
Slightly  magnified,  they  have  a  large,  uniform,  yellow 
central  zone  surrounded  by  a  border  composed  of  per- 
pendicular threads  placed  thickly  together.  Sometimes 
a  series  of  these  rings  appear,  with  intervening  yellow 
rings. 

"Agar:  The  colonies  are  round,  spread  out,  and  blue 
or  bluish  white.  Slightly  magnified,  they  have  a  pale- 
yellow  color. 

"Stab  Cultures. — Gelatin:  In  sugar  gelatin  the  sur- 
face growth  has  a  nearly  colorless  centre  surrounded  by  a 
thick  border,  with  an  outer  edge  of  fine,  hair-like  fringe; 
the  growth  along  the  line  of  inoculation  is  fine  and  deli- 


BACILLUS    "E"   OF   BOOKER.  45 

cate.  In  neutral  gelatin  the  growth  is  not  so  luxuriant 
as  on  sugar  gelatin;  on  the  surface  it  is  thick  and  white, 
with  a  delicate  stalk  in  the  depth. 

"Agar:  Thick  white  surface  growth,  with  a  well- 
developed  stalk  in  the  depth. 

"Potato:  Luxuriant  yellow,  glistening,  moist,  and 
slightly  raised  surface,  with  well-defined  borders. 

''Action  on  Milk. — Coagulated  into  a  gelatinous  coag- 
ulum  in  twenty-four  hours  at  38°  C,  and  into  a  solid  clot 
in  two  days. 

"Milk-Litmus  Reaction. — Milk  colored  blue  with  lit- 
mus is  changed  to  light  pink  in  twenty-four  hours  at  38° 
C.  The  pink  color  gradually  fades,  and  by  the  second  or 
third  day  is  white  or  cream  color,  with  a  thin  layer  of 
pink  on  top.  The  pink  color  extends  in  a  few  days  about 
one-half  down  the  clot. 

"Temperature. — Grows  best  about  38°  C. 

"Spores  have  not  been  observed. 

"Gas-production. — Gas-bubbles  are  produced  in  milk; 
not  observed  on  potato." 


"Found  as  the  predominating  form  in  two  cases  of 
dysentery,  one  of  which  was  fatal  and  the  other  a  mild 
case. 

"Morphology. — Resembles  bacterium  coli  commune. 

"Growth  in  Colonies. — Gelatin:  The  colony  growth 
varies  considerably  with  slight  difference  in  the  gelatin. 
In  10-per-cent.  neutral  gelatin  the  colonies  resemble  those 
of  bacterium  coli  commune.  On  the  second  or  third  day, 
when  the  colonies  have  just  broken  through  the  surface 
and  are  spread  out,  it  is  impossible  to  distinguish  one 
variety  from  the  other,  but  as  the  colonies  grow  older 
a  difference  can  general]  y  be  recognized.  In  sugar  and 
acid  gelatin  the  colonies  have  a  clear  centre  with  white 
border.  Slightly  magnified,  a  uniform  brown  centre  sur- 
rounded by  a  brown  zone  composed  of  fine,  needle-like 


46  INFANT-FEEDING. 

rays  perpendicular  to  the  border.  After  cultivating  for 
a  few  generations  on  acid  and  sugar  gelatin  the  colonies 
cease  to  develop,  and  either  grow  in  very  small  colonies 
or  do  not  grow  at  all.  The  activity  is  regained  if  culti- 
vated on  neutral  gelatin. 

"Agar :  Colonies  are  large,  round,  and  have  a  mother- 
of-pearl  appearance.  Slightly  magnified,  a  uniform  yel- 
low color. 

"Stab  Cultures. — Agar:  Luxuriant,  nearly  colorless 
surface  growth,  with  well-developed  stalk  along  the  line 
of  inoculation  in  the  depth. 

"Potato:  Golden-yellow,  glistening,  slightly  raised 
surface,  with  well-defined  borders. 

"Action  on  Milk. — Milk  becomes  gelatinous  in  twenty- 
four  hours  at  38°  C,  and  in  a  few  days  a  solid  coagulum 
is  formed.  Milk  colored  blue  with  litmus  is  reduced  to 
white  or  cream  color  in  twenty-four  to  forty-eight  hours 
at  38°  C,  with  a  thin  layer  of  pink  at  the  top  of  the 
culture.  The  pink  color  gradually  extends  lower  in  the 
coagulum. 

"Temperature. — Thrives  best  at  about  38°  C. 

"Spores  have  not  been  observed. 

"Gas-production. — Occurs  in  milk,  but  not  seen  in 
potato  cultures. 

"Relation  to  Gelatin. — Does  not  liquefy  gelatin. 

"Resemblance. — Resembles  bacterium  coli  commune 
and  bacillus  'd,'  differing  from  the  former  in  the  charac- 
ter of  the  colony  growth  on  acid  and  sugar  gelatin  and  in 
ceasing  to  develop  in  these  media  after  several  genera- 
tions.    It  differs  from  bacillus  'd'  in  this  latter  respect." 

BACILLUS    "f"    OF    BOOKER. 

"Found  in  one  case  of  cholera  infantum  and  one  case 
of  catarrhal  enteritis. 

"Morphology. — Resembles  bacterium  coli  commune. 

"Growth  in  Colonies. — Gelatin:  It  is  difficult  to  dis- 
tinguish the  colony  growth  from  the  bacterium  coli  com- 


BACILLUS    "f"   OF   BOOKER.  47 

mime.  There  is  often  a  difference  in  the  colonies  planted 
at  the  same  time  and  kept  under  similar  conditions,  but 
it  is  not  very  marked  nor  always  the  same  kind  of  differ- 
ence. The  tendency  to  concentric  rings  is  greater  in  this 
variety.  The  colonies  develop  somewhat  better  on  neutral 
and  sugar  gelatin  than  on  acid  gelatin. 

"Agar:  The  colonies  are  large,  round,  and  bluish 
white.     Slightly  magnified,  a  light-yellow  color. 

"Stab  Cultures.- — Gelatin :  The  culture  is  spread  over 
the  surface  and  has  a  mist-like  appearance;  in  the  depth 
along  the  line  of  inoculation  is  a  delicate  stalk. 

"Agar:  Thick,  luxuriant,  white  surface  growth,  with 
a  well-developed  stalk  along  the  line  of  inoculation  in  the 
depth. 

"Potato:  Bright-yellow,  glistening,  moist  surface, 
with  well-defined  borders,  and  but  slightly  raised  above 
the  surrounding  potato. 

"Action  on  Milk  and  Litmus  Reaction. — Milk  is  co- 
agulated into  a  solid  clot  in  twenty-four  hours  at  38°  C, 
and  in  forty-eight  hours  is  reduced  to  white  or  cream 
color  with  a  thin  pink  layer  on  top. 

"Gas-production. — Gas-bubbles  arise  in  milk  cultures, 
but  they  have  not  been  observed  on  potato  cultures. 

"Temperature. — Grows  better  at  38°  C. 

"Spores  have  not  been  observed. 

"Relation  to  Gelatin. — Does  not  liquefy  gelatin. 

"Resemblance.  —  It  closely  resembles  bacterium  coli 
commune  and  Brieger's  bacillus  in  the  character  of  its 
growth  upon  different  media,  but  is  readily  distinguished 
from  both,  as  is  also  Brieger's  bacillus  from  the  bacterium 
coli  commune,  by  the  following  differential  test  recently 
made  known  by  Dr.  Mall:  Yellow  elastic  tissue  from  the 
ligamentum  nuchse  of  an  ox  is  cut  into  fine  bits  and  is 
placed  in  test-tubes  containing  water  with  10-per-cent. 
bouillon  and  1-per-cent.  sugar,  and  sterilized  from  one 
and  one-half  to  two  hours  at  a  time  for  three  consecutive 
days.     Into  this  is  inoculated  two  species  of  bacteria,  one 


48  INFANT-FEEDING. 

of  which  is  the  bacterium  under  observation,  the  other  a 
bacillus  found  in  garden  earth.  The  latter  bacillus  is 
anaerobic;  grows  in  hydrogen,  nitrogen,  and  ordinary 
illuminating  gas;  in  the  bottom  of  bouillon;  in  the  depth, 
but  not  on  the  surface,  of  agar  stab  cultures,  and  not  at 
all  in  gelatin  stab  cultures.  It  has  a  spore  in  one  end, 
making  a  knob  bacillus.  Different  species  of  bacteria — 
streptococcus  Indicus,  tetragenus,  cholera,  swine  plague, 
bacterium  lactis  aerogenes,  bacterium  coli  commune, 
Brieger's  bacillus,  and  a  number  of  varieties  of  bacteria 
which  I  have  isolated  from  the  fasces — were  inoculated 
with  head  bacillus  into  the  above-described  elastic-tissue 
tubes.  The  tubes  inoculated  with  Brieger's  bacillus  de- 
velop a  beautiful  purple  tint,  which  started  as  a  narrow 
ring  at  the  top  of  the  culture,  gradually  extending  down- 
ward and  deepening  in  color  until  the  whole  tube  has  a 
dark-purple  color.  This  color-reaction  began  in  five  to 
fourteen  days,  and  was  constantly  present  in  a  large  num- 
ber of  tests.  Tubes  inoculated  with  bacillus  '¥  gave  a 
much  fainter  purple  color,  which  was  longer  in  appearing 
and  never  became  so  dark  as  with  Brieger's  bacillus. 

"Tubes  inoculated  with  the  other  species  of  bacteria 
above  mentioned  gave  no  color-change  and  remained  simi- 
lar to  control.  Bacillus  '¥  also  shows  a  slight  difference 
from  bacterium  coli  commune  in  coagulating  milk  and 
reducing  litmus  more  rapidly,  and  appears  to  produce 
more  active  fermentation  in  milk.  Like  Brieger's  bacillus, 
the  gelatin  colonies  more  frequently  show  a  concentric 
arrangement  than  those  of  the  bacterium  coli  commune." 

BACILLUS    "g"    OF    BOOKER. 

"Found  in  one  case  of  serious  gastro-enteric  catarrh. 
It  was  not  in  large  quantity. 

"Morphology  and  Biological  Characters.  —  In  mor- 
phology, character  of  growth  on  agar,  gelatin,  and  potato, 
it  resembles  bacterium  coli  commune. 


BACILLI   "h"  AND   "k"  OP  BOOKER.  49 

"Action  on  Milk  and  Litmus  Reaction. — Milk  is  not 
coagulated,  and  milk  colored  blue  with  litmus  is  changed 
to  pink  in  a  few  days,  and  holds  this  color.  These  charac- 
teristics distinguish  it  from  the  bacterium  coli  commune. 

"Gas-production.  —  ISTot  observed  in  milk  or  potato 
cultures. 

"Relation  to  Gelatin. — Does  not  liquefy  gelatin." 

BACILLUS    "h"    OF    BOOKER. 

"Found  in  one  case  of  mild  dysentery,  not  in  large 
quantity. 

"Morpliology. — Resembles  bacterium  coli  commune. 

"Growth  in  Colonies.  —  Gelatin:  In  plain  neutral 
gelatin  the  colonies  resemble  those  of  bacterium  coli  com- 
mune. In  sugar  gelatin  the  colonies  are  white  and  spread 
extensively.  Slightly  magnified,  they  have  a  round,  dark 
centre  surrounded  by  a  yellow,  loose  zone  with  an  outer 
white  rim;  later  the  whole  colony  has  a  uniform  yellow 
color  and  is  not  compact. 

"Agar :  Colonies  are  white,  round,  and  large.  Slightly 
magnified,  they  are  brownish  yellow. 

"Stab  Cultures.  —  Nothing  characteristic  in  gelatin 
and  agar. 

"Potato  culture  is  yellow,  dry,  and  slightly  raised, 
with  well-defined  borders. 

"Action  on  Milk  and  Litmus  Reaction. — Milk  is  co- 
agulated into  a  solid  clot  in  two  days  at  38°  C.  Milk 
colored  blue  with  litmus  is  changed  to  pink  in  twenty-four 
hours. 

"Gas-production. — Occurs  in  milk;  not  observed  on 
potato. 

"Relation  to  Gelatin. — Does  not  liquefy  gelatin." 

BACILLUS    "k"    OF    BOOKER. 

"Found  in  two  cases  of  cholera  infantum  and  one  of 
catarrhal  enteritis. 


50  INFANT-FEEDING. 

"Morphology. — Resembles  bacterium  coli  commune. 

"Growth  in  Colonies.  —  Gelatin:  In  neutral  gelatin 
the  colonies  cannot  be  distinguished  from  those  of  bac- 
terium coli  commune.  In  acid  gelatin  the  colonies  do  not 
spread  so  extensively  as  those  of  bacterium  coli  commune, 
and  they  have  a  decided  concentric  arrangement;  a  wide 
white  centre  surrounded  by  a  narrow,  transparent  blue 
ring;  and  outside  of  this  a  white  border.  Slightly  mag- 
nified, the  colonies  have  an  irregular,  yellowish-brown 
centre,  mottled  over  with  dark  spots  and  surrounded  by 
a  light-yellow  ring  bordered  by  a  brownish-yellow  wreath. 

"Agar:  Colonies  are  large,  round,  and  bluish  white. 
Slightly  magnified,  a  light-brownish-yellow  color. 

"Stab  Cultures. — Gelatin:  In  sugar  gelatin  the  sur- 
face growth  is  extensive;  nearly  colorless;  and  has  a 
rough,  misty  appearance.  In  the  depth  is  a  delicate 
growth.  In  plain  neutral  gelatin  the  surface  growth  is 
bluish  white,  thick,  and  not  so  extensively  spread;  the 
growth  in  the  depth  is  also  thicker. 

"Potato  culture  is  moist,  dirty-cream  color,  has  raised 
surface  and  defined  border. 

"Action  on  Milk.- — Milk  becomes  gelatinous  in  twenty- 
four  hours  at  38°  C,  and  a  solid  clot  in  two  days.  Milk 
colored  blue  with  litmus  is  changed  to  pink  in  twenty- 
four  hours,  and  reduced  to  white,  with  a  pink  layer  on 
top,  in  two  days." 

BACILLUS    "n"    OF    BOOKEK. 

"Eound  in  large  quantity,  but  not  the  predominating 
form,  in  one  case  of  chronic  gastro-enteric  catarrh  (ex- 
tremely emaciated). 

"Morphology. — Resembles  bacterium  coli  commune. 

"Growth  in  Colonies.  —  Gelatin:  In  neutral  gelatin 
the  colonies  are  spread  out  and  have  a  frosty,  or  ground- 
glass,  appearance.  The  centre  is  blue  and  border  white, 
but  both  have  the  ground-glass  appearance.  Slightly  mag- 
nified, the  central  part  is  light  yellow  and  the  border 


BACTERIUM  LACTUS  AEROGENES.  51 

brown,  with  a  rough,  furrowed  surface.     In  acid  gelatin 
the  white  border  is  wider  and  the  surface  is  rougher. 

"Agar :  Colonies  are  round,  blue,  or  bluish  white,  and 
spread  out.  Under  the  microscope  they  have  a  light-yel- 
low color. 

"Stab  Cultures. — Gelatin:  Has  a  rough,  nearly  color- 
less surface  growth,  and  a  thick  stalk  in  the  depth  along 
the  line  of  inoculation. 

"Agar:    Thick  white  surface  growth,  with  well-devel- 
oped stalk  in  the  depth. 

"Action  on  Milk  and  Litmus  Reaction.  —  Milk  re- 
mains liquid  and  milk  colored  blue  with  litmus  is  changed 
to  pink. 

"Gas-production.  —  ISTot  observed  in  milk  or  potato 
cultures. 

"Relation  to  Gelatin. — Does  not  liquefy  gelatin. 

"Spores  have  not  been  noticed."16 

BACTERIUM    LACTIS    AEROGENES. 

Synonym. — Bacillus  lactis  aercgenes  (Escherich). 

Obtained  by  Escherich  (1886)  from  the  contents  of 
the  small  intestine  of  children  and  animals  fed  on  milk; 
in  smaller  numbers  from  the  faeces  of  milk-fed  children, 
and  in  one  instance  from  uncooked  cows'  milk. 

Morphology.  —  Short  rods  with  rounded  ends,  from 
1  to  2  microns  in  length  and  from  0.1  to  0.5  micron 
broad;  short-oval  and  spherical  forms  are  also  frequently 
observed,  and  under  certain  circumstances  longer  rods — 
3  microns — may  be  developed;  usually  united  in  pairs, 
and  occasionally  in  chains  containing  several  elements. 
In  some  of  the  larger  cells  Escherich  has  observed  un- 
stained spaces,  but  was  not  able  to  obtain  any  evidence 
that  these  represent  spores. 

This  bacillus  stains  readily  with  the  ordinary  aniline 
colors,  but  does  not  retain  its  color  when  treated  by 
Gram's  method. 


16  Sternberg's  "Manual  of  Bacteriology,"  1892. 


52  INFANT-FEEDING. 

Biological  Characters. — An  aerobic  (facultative  an- 
aerobic), non-liquefying,  non-motile  bacillus.  Does  not 
form  spores.  Grows  in  various  culture-media  at  the  room- 
temperature — more  rapidly  in  the  incubating  oven.  Upon 
gelatin  plates,  at  the  end  of  twenty-fours  hours,  small, 
white  colonies  are  developed.  Upon  the  surface  these 
form  hemispherical,  soft,  shining  masses  which,  examined 
under  the  microscope,  are  found  to  be  homogeneous  and 
opaque,  with  a  whitish  lustre  by  reflected  light.  The  deep 
colonies  are  spherical  and  opaque,  and  attain  a  consider- 
able size.  In  gelatin  stick  cultures  the  growth  resembles 
that  of  Friedlander's  bacillus;  i.e.,  an  abundant  growth 
along  the  line  of  puncture  and  a  rounded  mass  upon  the 
surface,  forming  a  "nail-shaped"  growth.  In  old  cult- 
ures the  upper  part  of  the  gelatin  is  sometimes  clouded, 
and  numerous  gas-bubbles  may  form  in  the  gelatin.  Upon 
the  surface  of  nutrient  agar  an  abundant,  soft,  white  layer 
is  developed.  Upon  old  potatoes,  in  the  incubating  oven, 
at  the  end  of  twenty-four  hours  a  yellowish-white  layer, 
several  millimetres  thick,  is  developed,  which  is  of  paste- 
like consistence  and  contains  about  the  periphery  a  con- 
siderable number  of  small  gas-bubbles;  this  layer  in- 
creases in  dimensions,  has  an  irregular  outline,  and  larger 
and  more  numerous  gas-bubbles  are  developed  about  the 
periphery,  some  the  size  of  a  pea ;  later  the  whole  surface 
of  the  potato  is  covered  with  a  creamy,  semifluid  mass 
filled  with  gas-bubbles.  On  young  potatoes  the  develop- 
ment is  different ;  a  rather  luxuriant,  thick,  white  or  pale- 
yellow  layer  is  formed,  which  is  tolerably  dry  and  has 
irregular  margins ;  the  surface  is  smooth  and  shining,  and 
a  few  minute  gas-bubbles  only  are  formed  after  several 
days. 

Pathogenesis. — Injections  of  a  considerable  quantity 
of  a  pure  culture  into  the  circulation  of  rabbits  and  of 
guinea-pigs  give  rise  to  a  fatal  result  within  forty-eight 
hours. 

In  his  first  publication  relating  to  "the  bacteria  found 


BACTERIUM  LACTUS  AEROGENES. 


53 


in  the  dejecta  of  infants  afflicted  with  summer  diarrhoea," 
Booker  has  described  a  bacillus  which  he  designates  by 
the  letter  "b,"  which  closely  resembles  bacillus  lactis 
aerogenes  and  is  probably  identical  with  it.  He  says: — 
"Summary  of  Bacillus  eb.' — Found  nearly  constantly 
in  cholera  infantum  and  catarrhal  enteritis,  and  generally 
the  predominating  form.  It  appeared  in  larger  quantities 
in  the  more  serious  cases.    It  was  not  found  in  the  dysen- 


Fig.  10. — Bacterium  Lactis  Aerogenes. 


teric  or  healthy  faeces.  It  resembles  the  description  of  the 
bacillus  lactis  aerogenes,  but  the  resemblance  does  not 
appear  sufficient  to  constitute  an  identity,  and,  in  the  ab- 
sence of  a  culture  of  the  latter  for  comparison,  it  is  con- 
sidered a  distinct  variety  for  the  following  reasons :  Bacil- 
lus 'b'  is  uniformly  larger,  its  ends  are  not  so  sharply 
rounded,  and  in  all  culture-media  long,  thick  filaments 
are  seen,  and  many  of  the  bacilli  have  the  protoplasm 
gathered  in  the  centre,  leaving  the  poles  clear.     There  is 


54  INFANT-FEEDING. 

some  difference  in  their  colony  growth  on  gelatin,  and  in 
gelatin  stick  cultures  bacillus  'b'  does  not  show  the  nail- 
form  growth  with  marked  end-swelling  in  the  depth.  In 
potato  cultures  the  bacillus  lactis  aerogenes  shows  a  differ- 
ence between  old  and  new  potatoes,  while  bacillus  'b'  does 
not  show  any  difference. 

"Bacillus  'b'  possesses  decided  pathogenic  properties, 
which  were  shown  both  by  hypodermic  injections  and 
feeding  with  milk  cultures." 


CHAPTER  IX. 

COLOSTRUM. 

Colostrum  is  found  in  the  breast  of  a  woman  several 
hours  after  birth.  It  resembles  milk,  but  is  a  much 
thinner  fluid.  It  is  always  the  forerunner  of  a  healthy 
normal  secretion  of  breast-milk,  which  usually  appears 
on  the  third  day  after  the  birth  of  the  infant. 

Colostrum  is  the  earliest  milk,  very  thin  and  watery 


Colostrum- 
corpuscles 


Fig.  11.— From  a  Drop  of  Milk  on  the  Third  Day  after  Deliv- 
ery, kindly  Furnished  by  Dr.  H.  L.  Collyer,  showing  Co- 
lostrum-corpuscles. The  specimen  drawn  by  Dr.  Julian  W. 
Brandeis.     (Zeiss  Ocular  4,  dd  Lens.) 


in  color,  very  rich  in  salts,  with  decided  purgative  prop- 
erties, saving  all  useless  castor-oil,  honey,  and  butter  and 
all  sugar-water,  with  which  mothers  and  nurses  delight 
to  experiment. 

According  to  Baginsky,  colostrum  contains  large 
quantities  of  serum-albumin,  is  also  very  rich  in  fat  and 
colostrum-corpuscles,    and   contains   a   large   quantity   of 

(55) 


56  INFANT-FEEDING. 

salts.     The  last  two  ingredients  are  supposed  to  be  the 
cause  of  the  laxative  action  of  the  colostrum. 

Immunity  by  Breast-milk. 

It  is  a  well-known  fact,  and  one  that  has  been  brought 
out  most  prominently  by  Brieger  and  Ehrlich  and  Bagin- 
sky,  that  immunity  can  be  conferred  on  a  child  by  nurs- 
ing the  milk  of  its  mother.  This  question  has  also  been 
studied  with  reference  to  conferring  immunity  in  infec- 
tious diseases,  and  H.  Neumann  has  found  that  immu- 
nity can  be  conveyed  to  an  infant  by  the  agency  of  breast- 
milk. 

The  Two  Mammary  Glands. 

The  two  mammary  glands  of  the  same  woman  may 
yield  somewhat  different  milk,  as  shown  by  Sourdat  and 
later  by  Brunner.  Also  the  different  portions  of  milk 
from  the  same  milking  may  have  different  compositions. 
The  first  portions  are  always  poorer  in  fat  (Parmentier, 
Peligot,  and  others). 

According  to  l'Heritier  Vernois  and  Becquerel,  the 
milk  of  blondes  contains  less  casein  than  that  of  bru- 
nettes: a  difference  which  Tolmatscheff  could  not  sub- 
stantiate. Women  of  weak  constitutions  yield  a  milk 
richer  in  solids,  especially  in  casein,  than  women  with 
strong  constitutions. 

According  to  Yernois  and  Becquerel,  the  age  of  the 
woman  has  an  effect  on  the  composition  of  the  milk,  so 
that  we  find  a  greater  quantity  of  proteids  and  fat  in 
women  15  to  20  years  old  and  a  smaller  quantity  of  sugar. 
The  smallest  quantity  of  proteids  and  the  greatest  quan- 
tity of  sugar  are  found  at  20  or  from  25  to  30  years  of 
age.  The  milk  with  the  first-born  is  richer  in  water — 
with  a  proportionate  diminution  of  the  quantity  of  casein, 
sugar,  and  fat — than  after  several  deliveries.  The  influ- 
ence of  menstruation  seems  to  slightly  diminish  the  milk- 
sugar  and  to  considerably  increase  the  fat  and  casein. 


witch's  milk.  57 


"Witch's  Milk. 


Witch's  milk  is  the  secretion  of  the  mammary  glands 
of  newborn  children  of  both  sexes  immediately  after  birth. 
This  secretion  has,  from  a  qualitative  standpoint,  the 
same  constitution  as  milk,  but  may  show  important  dif- 
ferences and  variations  from  a  quantitative  point  of  view. 
Schlossberger  and  HaufT,  Gubler  and  Quevenne,  and  von 
Gesner  have  made  analyses  of  this  milk,  and  give  the 
following  results:  10.5-28  p.  m.  proteids,  8.2-14.6  p.  m. 
fat,  and  9-60  p.  m.  sugar. 

The  newborn  human  infant  almost  constantly  se- 
cretes a  fluid  in  the  mammas,  and  adult  males  have  not 
only  secreted  milk,  but  that  in  abundance  enough  to 
suckle.  Females,  also,  both  human  and  animal,  occasion- 
ally secrete  milk  without  having  been  previously  preg- 
nant. "With  regard  to  the  milk  secreted  by  infants,  there 
is  some  doubt  about  its  real  nature.  Kollicker  does  not 
view  it  as  a  true  milk,  but  considers  its  appearance  con- 
nected with  the  formation  of  the  mammary  glands. 

Sinety,  on  the  other  hand,  upon  anatomical  grounds 
considers  it  a  true  lacteal  secretion.  It  probably  is  a  sort 
of  imperfect  milk,  loaded  with  leucocytes,  and  this  is 
the  more  likely  as  Vollard17  notices  that  it  frequently 
ends  in  abscess. 

Schlossberger  gives  an  imperfect  quantitative  anal- 
ysis of  a  sample  of  milk  obtained  by  squeezing  the  breasts 
of  a  newborn  infant,  a  male.  In  the  course  of  a  few  days 
about  a  drachm  was  obtained.  The  following  was  the 
result  of  the  analysis: — 

Water 96.75 

Fat    0.82 

Ash  0.05 

Casein,  sugar,  and  extractives 2.83 

Sugar-reaction   strong. 


17  "Traite  des  Maladies  des  Enfants  nouveau-nes,"  third  edition, 
1837,  p.  717. 


58  INFANT-FEEDING. 

The  most  complete  analysis  we  possess  of  such  milk 
is  by  von  Gesner: — 

Milk-fat     1.456 

Casein    0.557 

Albumin    0.490 

Milk-sugar    0.956 

Ash  0.826 

Water    95.705 

Total  solids   4.295 


Joly  and  Filhol  have  recorded  the  case  of  an  old  lady, 
T5  years  of  age,  who  suckled  successfully  her  grandchild. 
Similar  instances  have  been  recorded  in  dogs,  and  we 
fortunately  possess  one  or  two  analyses  which  show  that 
the  fluid  is  certainly  milk.  Thus,  Filhol  and  Joly  give 
the  following  analysis  of  the  milk  derived  from  a  bitch 
which  had  no  connection  with  a  male: — 

Specific  gravity   1.069 

Total  solids   29.00 

Fat    2.20 

Sugar   0.32 

Albumin    23.20 


The  ash,  on  analysis,  gave  the  following  percentage : 

Chloride  of  sodium 65.10 

Chloride   of  potassium 3.88 

Calcic   phosphate    27.75 

Sodic  phosphate   1.40 

Sodic   carbonate    1.87 

Traces  of  magnesia  and  other  phosphates. 


Men  Suckling  Children. 

Men  before  now  have  suckled  children.  Humboldt 
relates  the  case  of  Francisco  Lozano,  whom  he  saw,  and 
whose   case   he   carefully   investigated;     and   it   appears 


MEN    SUCKLING    CHILDREN".  59 

established  that  this  man  did  secrete  from  his  breasts  a 
nutrient  fluid,  on  which  his  infant  son  lived  for  many 
months;  it  is  said,  indeed,  a  whole  year.  The  curious 
in  such  matters  may  consult  the  references  given  farther 
on.18 


18 1.  "Untersuchung  der  sogenannte  Hexenmilch."  J.  Schloss- 
berger,  Annalen  der  Chemie  und  Pharmacie,  B.  87,  1852.  2.  Robert 
Bishop  of  Cork:  letter  concerning  a  man  who  gave  suck  to  a  child. 
Phil.  Trans.,  1741,  No.  461,  page  813,  etc. 


CHAPTER  X. 

Breast-milk. 

According  to  PfeifTer,  human  milk  contains,  several 
days  after  the  birth  of  the  baby,  a  large  quantity  of  albu- 
min, salt,  and  a  small  quantity  of  fat.     He  also  found 


'ors 


Fig.  12. — This  Illustration  was  Drawn  by  Dr.  J.  W.  Brandeis 
from  a  Drop  of  Breast-milk  Taken  from  a  Wet-nurse  Em- 
ployed in  the  Author's  Family.  It  Represents  a  Beautiful 
Emulsion  of  Evenly-Divided  Fat-globules.  Note  the  Reg- 
ularity of  their  Size. 


that  the   longer  the  period   of  nursing  the   smaller   flic 
quantity  of  albumin,  which,  in  the  eleventh  month,  sinks 
(60) 


BREAST-MILK. 


61 


Fig, 


13.— Showing  a  Drop  of  Milk  under  the  Microscope.  Note 
the  poor  character  of  this  emulsion,  the  uneven  fat-globules, 
and  their  irregular  size  and  distribution.  The  infant  nursed 
with  the  above  milk  was  rachitic  and  colicky.  Although 
15  months  old,  no  tooth  had  appeared.  The  mother  of  the 
infant  states  that  she  menstruated  every  twenty-one  or 
twenty-two  days  since  her  infant  was  born — during  this 
present  nursing  period. 


Fig.  14. — This  Drop  of  Breast-milk  is  from  a  very  Anaemic 
Woman.  The  child  was  extremely  emaciated;  had  greenish 
stools,  and  colic,  and  was  always  crying.  Note  the  uneven 
character  of  above  emulsion,  when  compared  with  Fig.  12. 
The  infant  was  poorly  nourished;  had  rickets  and  marked 
cranio-tabes.  Mixed  feeding  was  resorted  to,  with  decided 
improvement. 


G2  INFANT-FEEDING. 

quite  low.  There  is  also  a  decrease  in  the  quantity  of 
salts,  whereas  the  amount  of  sugar  steadily  increases. 
The  fat  varies  constantly.  According  to  Johannessen, 
the  quantity  of  albumin  in  the  first  six  months  is  1.192 
per  cent.;  in  the  next  six  months  0.989  per  cent.;  and 
at  the  end  of  the  year  0.907  per  cent. 

Breast-milk  varies  according  to  the  length  of  time 
that  it  remains  in  the  breast,  and  also  the  length  of  the 
nursing  period;  so  it  has  been  shown  that  the  first  milk 
taken  at  the  beginning  of  the  nursing  act  is  the  poorest 
in  nutrient  value,  whereas  the  last  milk  is  richest  in  fat. 
The  longer  the  milk  remains  in  the  glands  of  the  breast, 
the  more  will  the  solid  substances  of  the  same  be  ab- 
sorbed, so  that  only  a  watery  solution  remains.  If  suck- 
ing is  commenced,  this  stimulation  soon  changes  the  char- 
acter of  this  watery  milk,  so  that  normal  milk  will  soon 
be  secreted.  Forster  studied  the  chemical  constitution 
of  the  first,  middle,  and  the  last  portions  of  milk  from 
a  nursing  woman,  with  the  following  result. 

In  one  hundred  parts  he  found: — 

First  Portion  of  the  Nursing  Act. 

Water    90.24 

Nitrogenous  substances    1.13 

Fat   1.70 

Sugar   5.56 

Ash 0.46 

The  quantity  examined  was  33.1  grammes. 


Second  Portion  (during  the  Nursing). 

Water    89.68 

Nitrogenous  substances   0.94 

Fat    2.77 

Sugar   5.70 

Ash 0.32 

The  quantity  examined  was  33.1  grammes. 


BREAST-MILK.  63 

Third  Portion  (at  the  End  of  the  Nursing  Act). 

Water    87.50 

Nitrogenous  substances   0.71 

Fat 4.51 

Sugar   5.10 

Ash 0.28 

The  quantity  examined  was  37.3  grammes. 

From  a  study  of  the  foregoing  tables  we  find  a  decrease 
of  nitrogenous  substances  during  the  course  of  the  nurs- 
ing, a  steady  increase  in  the  amount'  of  fat,  and  an  un- 
varying percentage  of  sugar.  Thus,  it  is  apparent  that, 
in  order  to  submit  a  specimen  of  breast-milk  to  a  chemical 
examination,  it  is  necessary  to  stimulate  the  secretory 
functions  of  the  mammary  glands  by  putting  the  child 
to  the  breast  at  least  two  minutes ;  thus  an  even  milk  can 
be  procured.  If  this  rule  is  overlooked,  then  we  shall  find 
proportions  in  the  chemical  components  of  milk  which 
might  otherwise  be  entirely  different.  The  most  recent 
chemical  analysis  of  breast-milk  shows  that  in  a  hundred 
parts  there  are: — 

Solids  11.5 

Liquids    88.5 

Of  the  solid  constituents  there  is : — 

Casein 1.2  to  1.03 

Albumin 0.5 

Fat     0.8  to  4.07 

Milk-sugar  6.0  to  7.03 

Ash    0.2  to  0.21 


The  above  is  the  chemical  examination  of  a  good 
average  breast-milk.  I  again  call  attention  to  the  fact, 
however,  that  not  only  does  the  milk  vary  in  different 
women,  but  it  also  varies  in  the  same  woman  during  one 
single  nursing  act. 


G4  INFANT-FEEDING. 

The  albuminoids  of  milk  consist  of  real  casein,  lac- 
talbumin,  globulin,  and  opalisin.  This  latter  body  has 
only  recently  been  discovered  by  A.  Wroblewski,  and 
more  recently  by  Schlossmann. 

Phosphorus  exists  in  milk  as  nuclein-phosphorus. 
Wittmaack  has  demonstrated  the  fact  that  the  phosphorus 
in  woman's  milk  exists  as  an  organic  nitrogen  compound 
in  the  casein. 

According  to  the  examination  of  Stolasa,  lecithin  con- 
tains a  larger  quantity  of  phosphorus  in  woman's  milk 
than  in  cows'  milk. 

The  specific  gravity  of  breast-milk  varies  from  1.026 
to  1.036. 


SPECIMEN    OF    BREAST-MILE:    FOE    CHEMICAL 
EXAMINATION. 

After  the  third,  possibly  the  fourth,  day  the  average 
healthy  woman  secretes  milk  that  gradually  becomes  nor- 
mal in  quality  and  quantity,  depending  on  her  general 
condition.  It  is  usual  for  an  infant  to  lose  some  weight 
during  its  first  week  of  life,  owing  to  various  physiological 
changes,  added  to  which  is,  no  doubt,  the  deficiency  in 
the  quality  and  quantity  of  its  food.  It  is  a  safe  plan, 
and  one  that  I  have  always  urged,  if  at  all  possible,  to 
send  a  specimen  of  breast-milk  to  a  chemist  and  submit 
the  same  to  a  chemical  analysis.  In  some  women  a  spec- 
imen can  be  examined  when  the  baby  is  one  week  old; 
in  others  it  is  better  to  wait  until  the  end  of  two  weeks. 
We  then  would  have  a  proper  working  basis,  and  know 
just  how  much  fat,  carbohydrate  (sugar),  and  albuminoids 
— including  proteids — we  are  feeding.  Noting  the  weight 
of  the  child,  its  sleep,  its  digestion,  color  and  frequency 
of  its  stools,  we  can  easily  see  in  one  week  how  much  the 
infant  has  gained  in  weight,  and  its  general  condition. 
To  take  a  specimen,  it  is  advisable  to  have  all  utensils 
absolutely  clean;   hence  the  following  plan  would  be  sug- 


BREAST-MILK. 


65 


gested:  Boil  an  ordinary  one-  or  two-  ounce  bottle  in 
water,  to  which  a  pinch  of  baking  soda  has  been  added, 
for  about  one-half  hour.  Then  place  the  bottle  in  plain 
water  and  boil  again  for  a  half-hour.  Then  turn  the 
bottle  upside  down,  and  allow  it  to  drain  and  dry.  In 
this  manner  we  can  completely  sterilize  the  inside  of  the 
bottle  and  avoid  contamination. 

Withdraw  a  sample  of  breast-milk  by  means  of  a 
breast-pump.  One  which  has  served  the  author  very  well 
is  known  as  the  Florence  breast-pump,  and  has  a  glass 
mouth-piece.  (See  illustration,  Fig.  17.)  Another  form 
is  an  English  breast-pump,  having  a  rubber  bulb.  Com- 
pressing this  bulb,  we  can  suck  about  an  ounce  or  more 
in  from  five  to  ten  minutes.  This  milk  is  to  be  poured 
into  the  bottle,  and  well  corked,  and  set  in  a  refrigerator, 
but  not  on  the  ice.  Milk  will  keep  for  many  hours  in 
this  way.     My  plan  has  been  to  inform  the  chemist  the 


Human  Mjlk. 

Fat. 

Pro- 

TEIDS. 

Sugar 

Ash. 

Authority. 

Normal  Milks. 

2.90 

3.07 

5.87 

0.16 

A.  W.  Blythe. 

3.68 

1.70 

7.11 

0.20 

Marchand. 

2.67 

3.92 

4.37 

0.14 

Vernois&  Becquerel. 

3.52 

2.01 

5.91 

Hammarsten. 

14  analyses  from 

same  woman    . 

2.53 

3.42 

4.82 

0.23 

Simon. 

Mean   of  6,  aged 

23-33  years  .    . 

3.82 

2.04 

5.93 

0.42 

H.  Gerber. 

3.55 

1.52 

6.50 

0.45 

Chevalier  &  Henry. 

From  woman  aged 

18 

3.20 

2.39 

683 

0.29 

J.  Bell. 

From  woman  aged 

33   .    .    . 

2.99 

2.51 

6.51 

0.30 

J.  Bell. 

4  days  after  deliv- 

ery .    

4.30 

3.53 

4.11 

0.21 

Clemm. 

9  days  after  deliv- 

ery  

3.53 

3.69 

4.30 

0.17 

Clemm. 

12  days  after  de- 

livery    .    . 

3.34 

2.91 

3.15 

0.19 

Clemm. 

Average  of  84 

samples .... 

4.13 

2.00 

6.94 

0.20 

Leeds. 

Average  of   10  7 

samples .... 

3.78 

2.09 

6.21 

0.31 

Konig. 

6Q  INFANT-FEEDING. 

day  previous  to  submitting  the  sample,  so  that  it  can  be 
withdrawn  from  the  breast  early  in  the  morning — at 
about  8  a.m. — and  sent  to  the  laboratory  at  once.  The 
result  of  the  analysis  can  be  received  on  the  evening  of 
the  same  day  or  on  the  following  day  in  all  instances.  A 
point  worth  noting  is  that  the  very  first  milk — known  as 
the  foremilk — should  not  be  used,  but  the  infant  should 
be  allowed  to  suck  at  the  breast  for  about  two  minutes 
before  pumping  the  sample.  After  this  the  breast-pump 
should  be  applied  for  five  minutes  to  procure  the  so-called 
middle  milk  for  examination;  then  the  infant  can  again 
be  put  to  the  breast  to  finish  the  so-called  end  of  nursing 
or  to  suck  the  strippings. 


CHAPTER  XL 


Bkeast-feeding. 


During  the  first  month  feed  every  two  hours  during 
the  day,  never  oftener.  During  the  second  month,  every 
two  and  a  half  to  three  hours.  The  child  may  be  taken 
from  its  sleep  during  the  day  to  be  nursed. 

Never  disturb  a  child  from  its  sleep  at  night  to  be 
nursed ;  so  that  the  rule  should  be  to  leave  the  baby  rest  as 
long  as  it  appears  satisfied.  This  rule  applies  to  healthy 
children  only.  In  sickness  special  feeding  rules  are  re- 
quired. If  the  child  thrives,  gains  in  weight,  then  it  is  ad- 
visable in  the  interest  of  the  mother  and  child  to  have  an 
interval  of  from  seven  to  eight  hours  at  night ;  thus  Bou- 
chut  advises  feeding  between  10  and  11  at  night  and  com- 
mencing the  morning  meal  at  6  a.m.  If  the  child  is  rest- 
less, then  turn  it  from  side  to  side ;  in  other  words,  chang- 
ing its  position  and  giving  it  1  or  2  teaspoonfuls  of  boiled 
water  will  frequently  satisfy  it  and  prolong  its  sleep. 

Time  foe  Feeding. 


From 

At 

Birth 

1  Month 

2  TO  4 

4  TO  6 

UNTIL  1 

until  2 

Months 

Months 

Month 

Months 

Old. 

Old. 

Old. 

Old. 

6  A.M. 

6  A.M. 

6  A.M. 

6  A.M. 

8  A.M. 

9  A.B1. 

9  A.M. 

9  A.M. 

10  A.M. 

11  A.M. 

12  Noon. 

12  Noon. 

12  Noon. 

1  P.M. 

3  P.M. 

3  P.M. 

2  P.M. 

3  P.M. 

6  P.M. 

6  P.M. 

4  P.M. 

5  P.Br. 

9  P.M. 

9  P.M. 

6  P.M. 

7  P.M. 

12  Mid- 

8 P.M. 

9  P.M. 

night. 

10  P.M. 

11  P.M. 

12  Mid- 

night. 

6  to  9 
Months  Old. 


6  A.M. 
9.30  to  10  A.M. 
1.30  to  2  P.M. 
5.30  to  6  p.m. 
9.30  to  10  p.m. 


9  Months 

until 

1  Year 

Old. 


6  A.M. 
10  A.M. 

2  P.M. 

6  P.M. 
10  P.M. 


(67) 


68  INFANT-FEEDING. 

The  first  three  or  four  days  after  birth  require  special 
feeding  methods: — 

On  the  day  of  the  birth,  the  exhaustion  of  the  mother 
and  presence  of  colostrum,  besides  the  normal  deficient 
quantity  of  food  in  the  breast,  demand  large  intervals  of 
rest;  thus  for  the  first  three  days  (unless  the  milk-supply 
is  profuse)  putting  the  infant  to  the  breast  once  every  six 
hours  would  be  sufficient;  if,  however,  the  supply  of  milk 
is  ample,  then  we  can  follow  the  table  given  above  and 
nurse  the  infant  every  two  hours. 

SUGGESTIONS    FOR    BKEAST-FEEDING. 

The  mother  or  wet-nurse  should  always  sit  upright, 
be  it  at  night  or  during  the  day,  while  nursing  the  infant. 

Danger  of  Suffocation. — A  great  many  cases  are  on 
record  where  the  mother  or  wet-nurse  has  fallen  asleep 
while  nursing,  and  smothered  the  child.  For  this  reason 
it  is  important  that  the  infant  should  sleep  in  its  own 
crib  or  bed,  and  should  never  sleep  with  its  mother  or 
nurse. 

Shall  an  Infant  Receive  but  One  or  Both  Breasts  for 
One  Meal? — This  depends  on  the  infant's  appetite.  Some 
infants  appear  satisfied  after  nursing  from  one  breast, 
and  will  let  the  nipple  go  and  fall  asleep.  Light  tapping 
on  the  cheeks  of  the  infant  will  awaken  it,  or  the  with- 
drawal of  the  nipple  from  the  infant's  mouth  will  fre- 
quently arouse  the  child  to  continue  its  nursing.  If, 
however,  an  infant  will  not  renew  its  nursing,  and  still 
continue  to  sleep,  and  if  the  infant  has  nursed  steadily 
for  ten  minutes,  then  the  sleep  should  not  be  disturbed. 

Length  of  Time  for  Nursing. — A  good  plan  is  to  note 
the  time  when  the  nursing  act  commences  and  stops.  ISTo 
infant  should  nurse  longer  than  20  minutes,  whereas  fre- 
quently 10  minutes  or  15  minutes  will  suffice.  If  an  in- 
fant nurses  more  than  20  minutes,  say  30  or  40  minutes, 
then  we  may  be  sure  that  the  breast-milk  is  deficient  in 


MIXED    FEEDING.  69 

quantity,  and  a  specimen  should  at  once  be  submitted  for 
a  proper  chemical  examination. 

Mixed  Feeding. 

When  there  is  a  deficiency  in  the  quantity  of  breast- 
milk,  but  the  quality  is  good,  then  it  is  advisable  to  feed 
the  infant  alternately  with  breast-milk  and  bottle-milk. 
At  the  same  time,  it  is  advisable  to  direct  attention  to  the 
mother's  general  condition,  and  see  if  we  cannot  tone  her 
up,  and  thus  improve  both  quality  and  quantity  of  her 
milk.  Frequently  a  subnormal  or  angemic  condition  re- 
quires iron;  in  other  cases  a  day's  outing  to  the  sea-shore 
or  to  the  country,  with  moderate  exercise,  will  stimulate 
and  increase  the  flow  of  milk.  It  is  well  to  try  some 
galactagogues.  Among  them  the  author  has  found  an 
albumin  diet  (meat,  milk,  and  eggs)  and  a  preparation 
known  as  nutrolactis  in  tablespoonful  doses  before  meals 
to  have  acted  very  well  in  some  cases.  Grandin  and 
Jarman,  in  their  text-book  on  obstetrics,  recommend  the 
strong  infusion  of  galega  officinalis  when  the  flow  of  milk 
is  scant.  This  is  to  be  ordered  in  tablespoonful  doses  three 
or  four  times  a  day.  Every  drop  of  breast-milk  is  so 
precious  that  no  infant  should  be  deprived  of  it,  and  wise 
is  the  physician  who  will  insist  on  giving  all  the  breast- 
milk  when  there  is  deficient  lactation,  and  supplying  the 
deficiency  by  giving  a  proper  diluted  milk-  or  cream- 
mixture,  adated  for  the  age  and  weight  of  the  infant. 

Do  Drugs  Taken  by  a  Nursing  Woman  Affect  the 
Baby  During  the  Nursing  Period?  —  Physiological  ex- 
periments have  frequently  demonstrated  the  fact  that  a 
great  many  drugs  can  be  given  to  an  infant  through  its 
mother's  milk;  thus,  opium  and  morphine  and  narcotics 
in  general  do  affect  the  nursling  when  the  drugs  are  taken 
by  the  mother.  Baginsky  calls  attention  to  this  fact  in 
his  text-book  on  "Diseases  of  Children" :  "Alcohol,  when 
taken  by  the  mother,  is  transmitted  through  the  milk,  but 
not  in  very  large  quantities.     The  following  is  a  list  of 


70  INFANT-FEEDING. 

drugs  which  have  been  found  in  milk:  The  purgative 
principles  of  rhubarb,  senna,  and  castor-oil;  the  metals 
antimony,  arsenic,  iodine,  bismuth,  lead,  iron,  mercury; 
the  volatile  oils,  like  copaiba,  garlic,  and  turpentine ;  also 
salicylic  acid,  and  the  iodides  and  bromides."  Do  not 
give  cocaine,  chloral,  atropine,  or  hyoscyamus.  Care  is 
to  be  used  with  the  .following:  Digitalis,  antipyrin,  and 
ergot.  An  unpleasant  flavor  can  be  imparted  to  the 
breast-milk  by  the  mother  or  wet-nurse  eating  onions, 
turnips,  cauliflower,  or  cabbage. 

Microbes  in  the  Milk  of  Nursing  "Women. 

Ringel19  examined  the  milk  of  25  women,  12  of 
whom  were  healthy.  With  minute  precaution  to  insure 
accuracy,  he  found  the  milk  sterile  in  only  3  cases;  he 
obtained  the  white  staphylococcus  in  17,  the  yellow  in  2, 
the  two  together  in  1  case,  and  in  2  instances  he  found 
the  white  staphylococcus  together  with  the  streptococcus. 
As  the  microbes  could  not  be  due  to  genital  infection, 
the  idea  was  suggested  that  they  might  come  from  the 
child's  mouth,  the  white  staphylococcus  having  been,  in 
fact,  found  on  the  child's  tongue.  But  having  examined 
the  milk  of  a  woman  who  had  not  been  suckling,  but 
whose  nipples  had  been  disinfected,  Eingel  still  found 
the  staphylococcus. 

Sterility  of  Human  Milk. 

Honigmann  finds  that  human  milk  obtained  with  all 
antiseptic  precautions  from  73  breasts  of  64  nursing 
women  was  only  sterile,  when  duly  cultivated,  in  4  cases. 
In  the  remainder  staphylococcus  albus  was  present,  and 
in  44  cases  the  staphylococcus  aureus;  while  in  3  in- 
stances other  bacteria — a  bacillus  and  a  sarcina — were 
found.     The  number  of  germs  varied  from  1  to  upward 


"Munch,  med.   Wochenschrift,   No.   27;    British   Gynaecological 
Journal,  xxxvij  Brooklyn  Medical  Journal,  August,  1894. 


ADDITIONAL   FOODS    DURING    NURSING    PERIOD.  71 

of  9000  in  a  cubic  millimetre.  These  observations  are  of 
interest  in  reference  to  the  occurrence  of  thrush  in  chil- 
.  dren,  to  the  origin  of  which  they  may  furnish  a  clew,  and 
also  to  the  liability  that  children,  while  suckling,  present 
to  suppuration  after  wounds  accidentally  or  intentionally 
inflicted.     {Lancet.) 

Fat-globules. 

Woman's  milk  has  larger  fat-globules  than  cows'  milk. 
Their  number,  according  to  Bouchut,  is  one  to  two  mil- 
lions in  1  cubic  centimetre.  It  has  less  inclination  to  turn 
acid;   therefore  it  does  not  coagulate  distinctly. 

Additional  Foods  During  the  Nursing  Period. 

Flour-Ball  Feeding. — When  an  infant  nursing  at  the 
breast  is  six  months  old  certain  additions  to  the  food  can 
safely  be  made;  thus,  for  example,  the  white  of  a  raw 
egg  can  be  given  every  second  day,  and  on  the  alternate 
day  several  teaspoonfuls  of  a  meat-soup  (beef  or  chicken) 
in  which  barley,  farina,  or  sago  has  been  boiled  and 
strained.  This  method  of  feeding  can  be  kept  up  until 
the  child  is  seven  or  even  eight  months  old,  and  then  a 
small  piece  of  zwieback  can  be  allowed  every  day.  As 
this  is  hard,  children  like  to  nibble  on  it,  for  it  seems  to 
soothe  their  gums.  If  the  bowels  are  in  a  good  condition, 
then  a  few  teaspoonfuls  of  a  very  light  wheat-flour  ball 
can  be  given  every  few  days.  Flour  ball  can  best  be  made 
by  following  the  directions  given  by  Dr.  Edwin  Rosenthal 
(Paper  read  before  the  Pennsylvania  State  Society,  May 
IS,  1898,  entitled  "Some  Points  on  Infant-feeding");  he 
says:  "I  use  the  following  formula,  and  I  can  claim  as 
much  good  results  therefrom  as  from  any  form  of  modi- 
fied home-made  food.  It  is  known  as  the  flour-ball  food, 
commercially  imperial  granum.  It  is  made  as  follows: 
Plain  wheat-flour  is  boiled  in  a  bag  for  five  hours,  then 
dried,  broken  open,  the  rind  rejected,  and  then  grated  into 
a  powder.    I  take  of  pure  milk,  mixed  and  scalded,  1  pint; 


72  INFANT-FEEDING. 

of  sterile  water,  1  pint;  of  the  boiled  flour,  a  heaping 
tablespoonful,  a  bit  of  cinnamon-bark  (sometimes  to  give 
some  flavor  with  certain  children),  and  a  pinch  of  com-, 
mon  table-salt.  The  milk  is  placed  on  the  fire  and  heated ; 
the  flour  is  rubbed  to  a  fine  paste  with  the  water,  and  then 
added  to  the  milk.  The  cinnamon  is  added,  and  then  it 
is  brought  to  the  boiling-point,  taken  from  the  fire,  the 
salt  added  (not  sufficient  to  taste),  and  the  whole  is  then 
placed  on  the  ice.  It  is  then  heated  again  when  used. 
Two  ounces  every  two  hours  is  given  to  a  child  one  month 
old.  It  is  increased  1/2  ounce  every  month,  while  the 
water  is  reduced  1  ounce  every  month.  The  milk  is  added 
to  keep  the  quantity  up  to  the  2  pints.  I  have  with  this 
method  seen  some  very  surprising  results,  and  feel  no 
hesitancy  in  recommending  it." 

The  Addition  of  Hydrochloric  Acid  to  Food.— -The 
indiscriminate  use  of  dilute  hydrochloric  acid  is  a  prac- 
tice that  is  to  be  condemned.  We  know  that  hydrochloric 
acid  passes  through  the  body  unchanged,  and  in  being 
excreted  by  the  kidneys  frequently  irritates  the  same.  A 
point  to  note  is  that  HC1  is  formed  in  the  stomach  from 
the  chlorides  in  the  circulation  of  the  blood.  It  appears, 
therefore,  quite  plausible  to  add  salt  to  the  infant's  food 
(ordinary  table-salt:  ISTaCl),  which  is  likely  to  be  trans- 
formed into  HC1  in  the  infant's  stomach. 

The  Feeding  of  Sick  Children. — The  method  of  feed- 
ing here  is  entirely  different  from  feeding  in  health.  xTo 
definite  rules  can  be  laid  down  as  to  the  quantity  or  the 
quality,  or  the  interval  required  for  feeding;  for  example, 
if  an  infant  suffering  with  dyspepsia  will  vomit,  and  have 
large,  cheesy  curds  in  the  stools,  and  have  anorexia,  such 
an  infant  requires  food  that  is  far  more  diluted  with  water 
than  heretofore.  If,  let  us  say,  an  infant,  two  months  old, 
suffer  with  dyspeptic  disturbance,  and  receives  2  parts  of 
milk  and  3  parts  of  water,  such  an  infant  should  be  given 
1  part  of  milk  with  3  parts  of  water,  to  see  if  the  dys- 
peptic condition  cannot  be  modified.     If  no  improvement 


THE    DIET    OF    A    NURSING    MOTHER.  73 

is  noted  after  several  days  of  such  feeding  then  it  is  wise 
to  substitute  barley-water  instead  of  plain  water,  and  thus 
see  if  the  digestibility  of  the  casein  cannot  be  improved. 
If,  however,  no  improvement  is  noted,  then  a  good  plan 
is  to  resort  to  predigested  foods.  It  is  in  this  class  of  cases 
that  peptonized  foods  are  so  advantageous;  but,  if  milk 
is  badly  borne,  then  it  should  be  diluted  with  dextrinized 
gruels. 

The  Diet  of  a  Nursing  Mother. 

Immediately  after  the  birth  of  the  child  the  exhausted 
condition  of  a  woman  following  labor  will  certainly  call 
for  rest;  hence  sleep  is  imperative,  after  which  some  form 
of  stimulation  is  required.  This  can  best  be  accomplished 
by  giving  at  intervals  of  several  hours  good  wholesome 
food,  as  broth  of  chicken,  or  beef-broth,  weak  tea,  or 
strained  gruel.  It  is  unnecessary  to  state  that  each 
woman's  case  and  her  former  habits  must  be  taken  into 
consideration;  and  thus,  if  the  labor  has  been  normal, 
the  nourishment  will  certainly  stimulate  the  flow  of  milk. 
,  Great  care,  however,  must  be  given  to  the  usual  irritable 
stomachs  in  this  condition,  and,  if  warm  liquids  are  not 
well  borne,  then  cold  drinks,  like  buttermilk,  koumiss, 
matzoon,  or  iced  tea,  should  be  employed.  In  some  in- 
stances ice-cream  will  aid  nutrition  and  allay  gastric  irri- 
tability. If  the  pelvic  condition  is  normal,  then  it  is  wise 
not  to  give  solid  food  for  the  first  three  days,  but,  rather, 
stimulate  the  milk-glands  by  giving  meat-broths,  farina- 
ceous gruels,  and  by  all  means  milk.  Zwieback  soaked 
in  milk  or  in  tea  is  highly  nutritious  and  easily  digestible. 
Other  nutritious  foods  are  calf's-foot  or  chicken  jelly. 

After  the  third  day — if  the  pelvic  organs  are  normal 
— it  is  wise  to  consider  the  action  of  the  bowels.  If  the 
bowels  have  not  moved  by  this  time,  then  buttermilk 
added  to  the  diet  or  some  stewed  prunes  or  baked  apples 
or  stewed  peaches,  or  grapes,  will  aid  in  establishing  a 
movement  of  the  bowels. 


74  INFANT-FEEDING. 

If  the  milk  is  scanty  and  the  bowels  have  not  acted, 
then  the  best  remedy  is  a  large  tablespoonfnl  of  castor-oil, 
modified  to  suit  the  taste  by  the  addition  of  either  orange- 
juice  or  lemon-juice,  or  by  adding  several  drops  of  the 
ordinary  spirit  of  peppermint.  After  the  bowels  have 
been  evacuated  and  the  general  condition  warrants  it, 
then  a  diet  consisting  of  the  following  is  indicated: — 

Bbeakfast,   7  to   8  A.M. 

Hominy  and  Milk.  Grapes. 

Farina  and  Milk.  Soft-boiled  Eggs. 

Rice  and  Milk.  Poached  Eggs. 

Oatmeal  and  Milk.  Eggs  on  Toast. 

Germea  and  Milk.  Coffee  and  Milk. 

Cream  of  "Wheat  and  Milk.       Tea  and  Milk. 
Some  Stewed  Prunes,  Eigs,       Cocoa  and  Milk. 

or  Peaches.  Toast  and  Butter. 

Stewed  Apples.  Stale  Bread  (2  days  old), 

Oranges.  with  Butter. 

I  do  not  advise  meat  or  fish  in  the  morning,  unless 
the  nursing  mother  has  always  been  accustomed  to  this 
form  of  diet. 

LUNCH,    12    TO    1    P.M. 

Some  soup,  made  from  meat — either  veal,  beef,  mut- 
ton, lamb,  or  chicken — and  containing  also  some  rice,  bar- 
ley, farina,  sago,  or  hominy;  it  should  not  be  highly  sea- 
soned, and  should  not  be  strained. 

Eish,  boiled  or  fried,  and  all  shell-fish,  particularly 
oysters,  are  very  nutritious  during  the  milking  period. 

If  the  appetite  warrants  it,  then  a  piece  of  steak  or 
chop,  roast  beef,  chicken  (white  meat  only),  or  raw 
chopped  meat,  with  bread  and  butter,  is  very  nutritious. 

Some  fruit. 


the  diet  of  a  nursing  mother.  75 

Evening,  6  to  7  p.m. 

A  bowl  of  Oatmeal  Gruel.       Junket. 
A  drink  of  milk.  Cup  of  Tea. 

Farina  Pudding.  Eggs,  if  desired. 

Kice  Pudding.  Meat,  if  in  the  habit  of  eat- 

Cornstarch  Pudding.  ing  it  in  the  evening. 

Some  Oysters  (stewed). 

For  Thirst.  —  Cool,  filtered  water  or  the  alkaline 
waters,  like  Seltzer  and  Apollinaris. 

If  the  milk  is  scanty,  the  flow  can  be  stimulated  by 
drinking  a  cup  of  hot  broth,  made  from  beef,  chicken, 
veal,  lamb,  or  mutton,  several  minutes  before  putting  the 
child  to  the  breast. 

Alcoholic  Drinks. — If  a  woman  is  in  the  habit  of 
drinking  beer  or  wine,  then  it  is  unwise  to  discontinue  the 
use  of  alcoholics  in  moderate  quantities,  while  she  is  nurs- 
ing. I  have  seen  a  great  many  women,  whose  flow  of  milk 
was  scant,  who  immediately  secreted  an  abundance  of 
.milk  after  partaking  of  a  glass  of  beer  or  ale  or  porter 
with  their  meals  for  several  days.  Beer  has  a  decided 
laxative  effect,  and  this  in  itself  is  rather  an  advantage 
for  those  nursing  mothers  having  a  tendency  to  constipa- 
tion. So,  my  rule,  therefore,  would  be  to  insist  on  ab- 
stinence from  wine  and  beer  unless  the  patient  has  been 
in  the  habit  of  taking  it  formerly. 

THINGS    TO    BE    AVOIDED    BY    A    NURSING    WOMAN. 

Onions.  Large    quantities    of   pota- 

Garlic.  toes. 

Cabbage.  Butter     and     fat,     except 

Powerful   salts    (Eochelle,  moderately. 

Glauber,  Epsom).  Candies     and     too     much 

Ethereal  oils.  sweets. 


CHAPTER  XII. 

Wet-nukse. 

If  the  infant's  own  mother  cannot  nurse  her  child, 
then  we  can  and  should  try  to  secure  a  wet-nurse. 

The  wet-nurse  must  be  carefully  examined,  as  well 
as  her  child,  for  the  presence  of  syphilis.  I  beg  to  refer 
to  a  short  paper  on  this  subject,  published  in  the  Amer- 
ican Medico-Surgical  Bulletin  in  January,  1894. 

1.  Never  have  a  baby  fed  by  the  milk  of  its  mother 
if  the  latter  suffer  with  general  debility  or  tuberculosis. 
Extremely  nervous  mothers  should  not  nurse  their  babies. 

Syphilitic  babies  (hereditary)  can  only  be  nursed  by 
their  own  mothers,  owing  to  the  risk  of  infecting  the  wet- 
nurse.  In  such  cases  very  frequently  the  life  of  the  child 
is  dependent  on  its  being  nursed  by  its  mother. 

The  following  general  rules  may  be  noted: — 

(a)  The  return  of  menstruation  is  no  contra-indication 
to  the  continuation  of  nursing. 

(b)  The  moment  a  woman  is  pregnant  nursing  should 
be  stopped. 

(c)  Children  should  not  be  nursed  at  night  unless  for 
some  special  reason. 

(d)  Weaning  should  take  place  gradually,  and  only 
in  the  eighth  to  the  tenth  month. 

(e)  It  is  understood  that  weaning  should  not  be  com- 
menced during  the  hot  summer  weather. 

The  main  factor  in  determining  the  time  of  weaning 
is  "weighing."  Children  must  be  weaned  when,  although 
in  perfect  good  health,  they  remain  below  normal  weight. 

(/)   Prolonged  nursing  will  induce  rachitis. 

2.  If,  for  various  reasons,  a  child  cannot  be  nursed 
by  its  own  mother,  we  then  resort  to  the  wet-nurse. 

(76) 


WET-NURSE.  77 

(a)  She  must  be  carefully  examined  as  to  her  phys- 
ical condition ;  tuberculosis,  all  chronic  disorders  and 
diseases  would  prevent  proper  nursing.  Hereditary 
nervous  troubles,  epilepsy,  or  syphilis  would  exclude 
nursing. 

(b)  It  is  a  good  point  to  try  to  procure  a  wet-nurse 
suckling  a  child  about  as  old  as  the  one  we  wish  her  to 
nurse,  although  it  is  quite  common  to  find  nurses  who 
have  older  children  than  the  one  they  wish  to  nurse  and 
to  find  the  latter  doing  well. 

(c)  The  proof  of  the  usefulness  of  the  wet-nurse  is 
the  condition  of  the  baby  after  some  time.  If  the  child 
thrives,  it  will  increase  in  weight.  Hence  scales  must  be 
frequently  used. 

DIET    OF    A    WET-NURSE. 

The  diet  given  for  a  nursing  mother  can  also  be  used 
as  a  guide  in  choosing  the  diet  for  a  wet-nurse.  The 
greatest  care,  however,  must  be  bestowed  on  the 

Manner  of  Living. — If  a  wet-nurse  was  formerly  a 
servant,  or  worked  out-of-doors  and  is  suddenly  taken  into 
this  new  mode  of  life  and  given  charge  of  a  baby,  she 
must  have  proper  exercise,  or  she  will  very  soon  secrete 
milk  totally  unfit  for  an  infant,  and,  as  a  result,  the  child 
will  probably  have  severe  colic  and  irregular,  cheesy 
stools;  will  vomit  excessively,  and  will  not  gain  suffi- 
ciently in  weight.  It  is,  therefore,  important  to  try  to 
adapt  a  wet-nurse  to  the  same  condition  as  existed  prior  to 
her  pregnancy,  so  that  both  her  manner  of  living  and, 
chiefly,  her  diet  shall  not  be  different. 

Proper  Rest. — To  be  equal  to  her  task  a  nurse  must 
be  given  plenty  of  sleep,  if  it  is  at  all  possible. 

Adriance,  in  the  Archives  of  Pediatrics,  says: — 

1.  Excessive  fats  or  proteids  may  cause  gastrointes- 
tinal symptoms  in  the  nursing  infant. 

2.  Excessive  fats  may  be  reduced  by  diminishing  the 
nitrogenous  elements  in  the  mother's  diet, 


78  INFANT-FEEDING. 

3.  Excessive  proteids  may  be  reduced  by  the  proper 
amount  of  exercise. 

4.  Excessive  proteids  are  especially  apt  to  cause  gastro- 
intestinal symptoms  during  the  colostrum  period. 

5.  The  proteids,  being  higher  during  the  colostrum 
period  of  premature  confinement,  present  dangers  to  the 
untimely-born  infant. 

6.  Deterioration  in  human  milk  is  marked  by  a  re- 
duction in  the  proteids  and  total  solids,  or  in  the  proteids 
alone. 

1.  This  deterioration  takes  place  normally  during  the 
later  months  of  lactation,  and,  unless  proper  additions  are 
made  to  the  infant's  diet,  is  accompanied  by  a  loss  of 
weight,  or  a  gain  below  the  normal  standard. 

8.  When  this  deterioration  occurs  earlier,  it  may  be 
the  forerunner  of  the  cessation  of  lactation,  or  well- 
directed  treatment  may  improve  the  condition  of  the 
milk. 

Methods  of  Changing  the  Ingredients  in 
"Woman's  Milk. 

]Rotch  gives  a  condensed  table  for  these  changes  as 
follows : — 

To  Increase  the  Total  Quantity. — Increase  the  liquids 
in  the  mother's  diet,  especially  milk  (malt-extracts  may 
be  helpful),  and  encourage  her  to  believe  that  she  will  be 
able  to  nurse  her  infant. 

To  Decrease  the  Total  Quantity. — Decrease  the  liquids 
in  the  mother's  diet. 

To  Increase  the  Total  Solids. — Shorten  the  nursing 
intervals,  decrease  the  exercise,  decrease  the  proportion 
of  liquids,  and  increase  the  proportion  of  solids  in  the 
mother's  diet. 

To  Decrease  the  Total  Solids. — Prolong  the  nursing 
intervals,  increase  the  exercise,  and  increase  the  propor- 
tion of  liquids  in  the  mother's  diet. 


WET-NURSING.  79 

To  Increase  the  Fat. — Increase  the  proportion  of  meat 
in  the  diet. 

To  Decrease  the  Fat.  —  Decrease  the  proportion  of 
meat  in  the  diet. 

To  Increase  the  Proteids. — Decrease  the  exercise. 

To  Decrease  the  Proteids. — Increase  the  exercise  up 
to  the  limit  of  fatigue  for  the  individual. 

It  is  wise  in  all  cases  of  disturbed  lactation,  whether 
in  maternal  or  wet-  nursing,  to  make  efforts  in  accordance 
with  these  rules  to  produce  a  milk  that  is  suitable  for  an 
infant  who  is  not  thriving,  before  changing  to  any  other 
method  of  feeding. 

Wet-nursing. 

It  is  an  established  fact  that  the  best  possible  food 
for  an  infant  is  breast-milk.  Where  the  mother  of  an 
infant  is  prevented  from  nursing  her  child,  the  next  thing 
to  be  considerd  is  wet-nursing.  That  nursing  a  child  is 
an  advantage  to  the  mother  is  a  well-known  fact,  inas- 
much as  it  influences  the  contraction  of  the  uterus  and 
stimulates  the  circulation.  Contrary  to  the  belief  that 
nursing  a  child  is  detrimental,  and  contra-indicated  in 
women  whose  lungs  are  weak  and  who  have  a  tendency 
to  the  development  of  tuberculosis,  it  does  them  no  harm, 
and,  indeed,  seems  to  do  them  good.  This  statement  is 
borne  out  by  the  experience  of  Dr.  Heinrich  Munk,  of 
Karlsbad,  Austria,  a  specialist  for  diseases  of  women. 

In  Austria  the  State  supports  public  institutions  for 
lying-in  women.  They  are  kept  there  and  confined  gratis, 
and  remain  about  fourteen  days.  They  are  admitted  into 
these  hospitals  in  the  last  months  of  pregnancy.  Vienna 
usually  has  about  300  women  on  hand.  Prague  con- 
stantly has  100  women  in  this  condition,  who  are  utilized 
for  the  purpose  of  instruction  to  physicians  and  midwives. 

In  Prague  there  are  about  3000  women  confined 
annually,  and  these  women  are  put  into  the  foundling- 


80  INFANT-FEEDING. 

asylum.  There  they  remain  until  they  procure  a  place 
as  a  wet-nurse  or  as  long  as  their  services  are  needed  in 
the  asylum.  When  wet-nurses  are  taken  from  the  found- 
ling-asylum, it  is  a  frequent  occurrence  to  have  those 
remaining  therein  nurse  at  least  two  children,  and  fre- 
quently three,  at  one  time.  In  this  manner  they  dispense 
gradually  with  these  wet-nurses  without  hurting  the  re- 
maining children.  Many  children  die,  some  of  them 
intrapartum  in  operative  confinements,  and  the  women 
(mothers  of  such  children)  are  then  utilized  for  wet- 
nursing.  It  is  a  rule  to  keep  the  children  in  the  asylum 
until  they  have  attained  a  little  over  four  kilogrammes 
(about  9  pounds),  and  they  are  then  put  out  for  further 
feeding  (artificial  feeding),  for  which  the  city  pays  about 
12  florins  a  month  ($5.00).  The  children  remain  usually 
until  they  are  six  years  old,  and  are  then  given  back  to 
their  own  mothers.  Many  of  these  children  die,  others 
are  adopted  by  those  who  have  reared  them,  but  the 
greater  portion  are  taken  back  by  their  own  mothers.  In 
Vienna  there  are  about  10,000  confinements  annually  in 
the  public  institution.  There  are  a  great  many  cities 
in  Austria — like  Innsbruck-Olmutz,  Brunn,  Linz,  and 
Klagenfurt — where  there  are  at  least  200  confinements 
annually.  In  Vienna  a  wet-nurse  receives  30  florins  per 
month,  for  which  she  is  sent  (railroad  expenses  paid)  to 
whoever  requires  her  services.  She  is  taken  on  trial  for 
fourteen  days,  to  see  if  she  is  adapted  for  her  place. 
A  wet-nurse  can  be  procured  by  sending  a  telegram  and 
a  money-order  any  day  during  the  year.  The  customary 
wages  are  from  12  florins  upward  per  month.  Each  wet- 
nurse  is -carefully  examined  by  the  professor  before  she 
is  sent  away.  A  great  many  families  do  not  care  to  take 
a  wet-nurse  from  an  asylum,  as  they  are  usually  women 
in  the  lowest  walks  of  life,  and  prefer,  therefore,  to  take 
a  woman  who  has  been  married.  Tor  this  purpose  there 
are  wet-nurse  agencies,  duly  licensed.  These  will  supply 
wet-nurses,  and  usually  take  orders  in  advance;    thus  a 


WET-NURSING.  81 

wet-nurse  may  be  reserved.  Suck  wet-nurses  cost  much, 
more,  and  those  from  one  special  region — Iglau  in  Mahren 
— receive  from  20  to  50  florins  monthly. 

The  empress  took  for  her  own  use  a  wet-nurse  from 
Iglau  (a  married  woman),  and  the  Princess  of  Bulgaria 
took  a  wet-nurse  from  Iglau  for  her  last  child.  Not  only 
Iglau,  but  the  whole  region,  is  renowned  for  its  excellent 
quality  of  wet-nurses.  The  Bohemian  and  Mahren  nurses 
have  very  good  mamma?.  They  seem  to  love  the  children 
intrusted  to  them. 

While  it  is  a  rule  that  a  wet-nurse  should  be  taken 
for  a  baby  of  the  same  age  as  that  of  her  own,  frequently 
wet-nursing  of  an  infant  at  birth  by  a  wet-nurse  whose 
baby  is  three  months  old  has  not  been  followed  by  any 
bad  results. 

In  !STew  York  we  are  at  a  decided  disadvantage  re- 
garding wet-nurses.  As  no  licensed  agencies  exist,  a  few 
people  having  so-called  influence  procure  wet-nurses  by 
friendship,  or  something  similar,  from  superintendents 
and  house  physicians  where  obstetrical  work  is  done. 

Thus  we  find  ourselves  at  the  mercy  of  some  people 
who  traffic  in  wet-nurses  for  a  fee,  usually  five  dollars, 
and  who  do  not  stop  at  anything  to  attain  their  own  selfish 
ends. 

Time  and  again  have  I  sent  for  a  wet-nurse  to  an 
agent  who,  instead  of  giving  me  a  healthy  wet-nurse,  tried 
to  induce  me  to  use  women  having  colostrum-milk  for 
an  infant  in  which  such  milk  would  have  proved  disas- 
trous. 

In  another  instance,  only  recently,  I  procured  a  wet- 
nurse  from  an  agent  who  sent  me  one  17  years  old,  who 
had  had  a  premature  birth,  "evidently  an  abortion,"  and 
whose  milk  was  typical  thin  water,  with  here  and  there 
a  fat-globule,  when  examined  under  the  microscope. 

At  other  times  some  of  the  finest  specimens  of  wet- 
nurses  have  also  been  procured  from  the  same  agent. 

It  is  a  pity  that  we  have  no  municipal  control  for  what 


82  INFANT-FEEDING. 

the  writer  considers  one  of  the  most  valuable  adjuncts  to 
our  maternal  feeding,  and  such  control  would  also  regu- 
late the  supply  to  such  unlimited  number  that  modern 
arrogance  on  the  part  of  the  wet-nurse  would  probably 
disappear. 

The  prices  paid  in  New  York  are  from  twenty  to 
thirty  dollars  per  month  and  board,  and  this  price  pro- 
hibits many  an  infant  from  securing  the  benefits  of 
Nature's  food.     Let  us  hope  for  municipal  regulation.20 

Weaning,  and  Feeding  fkom  One  Year  to 
Fifteen  Months. 

Weaning  should  take  place  gradually  between  the 
eighth  and  tenth  months.  In  some  instances  it  is  advis- 
able to  commence  weaning  a  child  much  sooner;  for  ex- 
ample, when  there  is  a  deficiency  in  the  supply  of  milk 
or  owing  to  ill  health  of  the  infant's  mother.  This  I 
have  already  mentioned  in  the  section  on  "Mixed  Feed- 
ing." 

Weaning  is  imperative  when  the  infant's  mother  is 
pregnant,  although  it  is  advisable  to  use  great  caution  if 
it  occur  in  midsummer.  In  a  case  of  this  kind  the  better 
plan  would  be  to  have  a  specimen  of  the  breast-milk  ex- 
amined by  a  chemist,  and,  if  the  same  be  found  deteri- 
orated in  quality,  then  the  judgment  of  the  physician 
must  prevail  as  to  the  advisability  of  continuing  or  dis- 
continuing the  nursing.  My  rule  has  been  not  to  wean 
during  the  summer  months. 

The  main  points  have  already  been  mentioned  in  this 
chapter  under  "Wet-nurse." 

Weaning  should  not  be  attempted  suddenly.  Thus, 
it  is  better  to  commence  weaning  gradually,  by  withdraw- 
ing the  breast  in  the  morning  and  substituting  a  bottle 
for  that  meal.     Following  this  meal  we  can  again  nurse 


20  The  attention  of  the  Department  of  Health  has  been  directed 
to  this  condition  in  New  York. 


WEANING,    AND    FEEDING    AFTER    WEANING.  83 

the  child  at  the  breast  for  two  feedings,  and  substitute  a 
bottle  for  its  fourth  meal  instead  of  the  breast.  In  this 
manner  we  can  feed  the  child  with  a  bottle  in  the  morn- 
ing, to  be  followed  in  three  or  four  hours  by  the  breast, 
then  at  the  next  feeding  again  nurse  the  child,  and  this 
to  be  followed  in  three  or  four  hours  by  the  bottle: — 

8.00  a.m Bottle. 

11.30  a.m Nursing. 

3.00  p.m Nursing. 

6.30  p.m Bottle. 

10.00  p.m Nursing. 

In  this  manner  we  can  see  just  how  the  food  is  as- 
similated, and  also  study  the  individual  peculiarities  of 
the  baby.  Some  children  are  very  hard  to  wean,  and  it 
will  require  great  tact  and  patience  to  successfully  cope 
with  this  condition.  In  consultation  I  recently  saw  a 
child  which,  on  being  removed  from  the  breast,  absolutely 
refused  to  take  the  bottle,  and  when  fed  with  a  'spoon  the 
child  would  spit  out  its  food.  After  three  or  four  days 
of  this  unsuccessful  weaning  the  physician  attempted 
more  heroic  methods,  and  insisted  on  isolating  the  child 
from  the  wet-nurse  for  twelve  consecutive  hours.  This 
infant  refused  to  take  food  even  after  that  time,  and  then 
it  was  that  I  was  summoned.  We  decided  to  give  pep- 
tonized milk,  alternating  with  peptonized  yolk  of  egg  by 
means  of  rectal  feeding.  Thus,  1  ounce  of  milk  and  1 
ounce  of  starch-water  were  injected,  followed  four  hours 
later  by  the  peptonized  yolk  of  egg  added  to  the  starch- 
water.  This  method  of  feeding  can  be  found  de- 
scribed in  detail  in  the  chapter  on  "Rectal  Feeding," 
and  also  in  the  chapter  on  "Feeding  in  Diphtheria  In- 
tubation Cases."  Thus  we  aimed  to  sustain  life  and 
avoid  starvation.  The  rectal  feeding  was  continued 
for  two  days  more,  when  the  child  suddenly  took  the 
bottle. 


84  INFANT-FEEDING. 

In  some  cases  forced  feeding  by  gavage  will  be  found 
useful.  If  the  child  holds  its  jaws  firmly,  the  catheter  can 
be  introduced  through  the  nasal  passage,  as  described  in 
the  section  on  "E"asal  Feeding." 

I  was  called  to  see  a  perfectly  healthy  child,  about 
9  months  old,  whose  mother  told  me  that  "he  would  not 
take  the  breast."  She  was  greatly  chagrined,  but  all 
efforts  at  nursing  him  proved  futile.  The  infant  had 
weaned  himself.  Such  cases  of  "self-weaning"  are  very 
rare. 

When  weaning  is  successfully  accomplished,  then 
great  care  must  be  exercised,  owing  to  the  change  in 
diet.  It  will  be  found  that  the  slightest  error  in  over- 
feeding or  too  frequent  feeding  will  be  rewarded  by  a 
severe  attack  of  dyspepsia  and  the  usual  gastric  disturb- 
ances, such  as  vomiting  and  fermentation  in  the  stomach, 
causing  diarrhoea  and  possibly  colic.  It  will  therefore 
be  very  necessary  to  exercise  good  judgment  in  the  choice 
of  both  quality  and  quantity  of  food  during  the  first 
month  or  two  after  weaning  or  until  the  stomach  adapts 
itself  to  this  new  way  of  feeding.  The  amylolytic  func- 
tion now  being  thoroughly  developed,  we  can  safely  give 
cereals. 

TIME    OF    FEEDING. 

Excepting  in  rare  instances,  after  a  child  is  weaned 
it  should  not  be  fed  oftener  than  once  in  four  hours.  The 
best  time  for  feeding  would  be  about  6  a.m.,  10  a.m.,  2 
p.m.,  6  p.m.,  and  10  p.m.  if  the  child  is  awake.  This  would 
give  eight  hours  rest,  and  healthy  children  can  be  trained 
to  sleep  that  length  of  time. 

The  first  bottle  after  sleeping  should  consist  of  8 
ounces  of  pure  cows'  milk.21  This  would  be  the  6-a.m. 
feeding. 

Four  hours  later,  or  at  10  a.m.,  the  infant  should 


21  The  best  milk   obtainable  in  this  city  is  undoubtedly  milk 
received  in  bottles  direct  from  the  dairy  the  same  day  of  milking. 


WEANING,  AND  FEEDING  AFTER  WEANING.       85 

receive  the  white  of  a  raw  egg,  fed  with  a  spoon  from 
a  wine-glass,  immediately  before  its  bottle,  which  con- 
sists of: — 

Cows'  milk  5  ounces. 

Barley-water    2  ounces. 

At  2  p.m.  our  next  feeding  should  consist  of  8  ounces 
of  pure  cows'  milk.  I  usually  permit  the  infant  to  nibble 
on  a  small  piece  of  the  ordinary  zwieback. 

The  evening  meal  at  6  p.m.: — 

Cows'  milk 6  ounces. 

Barley-water    2  ounces. 

The  last  feeding,  at  10  p.m.,  if  the  child  is  awake,  or 
at  midnight  should  consist  of  8  ounces  of  pure  cows' 
milk. 

When  milk  is  brought  from  the  dairy  there  is  a  thick 
layer  of  cream  on  the  top  of  the  milk,  which  should  be 
thoroughly  mixed  with  the  milk  by  shaking  the  bottle,  so 
that  the  infant  receives  a  thoroughly  mixed  milk  contain- 
ing the  same  quantity  of  cream  in  each  feeding.  The 
milk  should  be  mixed  and  the  barley-water  added  to  it. 
It  is  then  poured  into  thoroughly  clean  bottles,  which  are 
stoppered  with  ordinary  cotton  stoppers.  This  can  be 
found  described  in  detail  in  the  chapter  on  "Sterilization." 
This  food  is  to  be  steamed  for  twenty  minutes  and  then 
allowed  to  cool  by  placing  the  bottles  in  a  refrigerator, 
but  not  on  the  ice.  When  ready  for  use  each  bottle  is 
to  be  warmed  to  a  temperature  of  about  100°  F.  for  the 
feeding.  If  constipation  follows  the  use  of  this  diet,  then 
a  good  plan  is  to  substitute  2  ounces  of  oatmeal-water 
instead  of  the  barley-water  above  mentioned.  When  the 
stools  are  regular  and  the  child  appears  to  be  quite  pale, 
then  great  good  can  be  accomplished  by  adding  2  ounces 
of  almond-milk  instead  of  the  oatmeal-  or  barley-  water: 
The  preparation  of  almond-milk  can  be  found  described 
in  the  "Dietary,"  to  which  I  beg  to  refer  my  readers.     If 


86  INFANT-FEEDING. 

a  severe  form  of  constipation,  with  cheesy  curds  in  the 
stools,  exists,  then  the  milk  should  not  be  steamed,  but 
fed  in  the  "raw  state."  It  is  understood  that  it  should 
be  warmed  to  the  body-heat  before  feeding  to  the  infant. 
Instead  of  giving  the  white  of  egg  every  day  I  substitute 
either  1  or  2  ounces  of  a  good  beef-soup  or  chicken-soup 
or  beef-tea  and  expressed  steak-juice,  and  feed  this  quan- 
tity immediately  before  the  10-a.m.  bottle  of  milk.  No 
distinct  change  of  food  will  be  necessary  until  the  child  is 
twelve  or  fifteen  months  old,  when  I  am  in  the  habit  of 
giving  either  1/2  saucer  of  oatmeal-gruel  with  some  butter 
or  some  hominy  and  butter  in  addition  to  a  morning 
bottle.  In  the  evening,  when  the  child  arrives  at  this  age, 
a  half-dozen  teaspoonfuls  of  junket  can  be  fed  before  the 
evening  bottle  of  milk.  When  a  child  is  over  one  year 
or  about  fifteen  months  old,  instead  of  giving  water  for 
thirst  I  frequently  give  prune-water  made  by  boiling 
good  fleshy  prunes  in  water  for  one-half  hour  and  strain- 
ing off  the  liquid.  When  oranges  can  be  procured,  one 
or  more  teaspoonfuls  of  orange-juice  can  be  given  with 
advantage.  Apple-sauce  can  also  be  given.  Thus,  my 
plan  consists  in  giving  each  one  of  these  foods  on  different 
days.  Just  at  this  period  the  addition  of  several  tea- 
spoons of  Mellin's  food  has  been  found  very  beneficial. 
Owing  to  gastric  derangements,  it  will  be  found  necessary 
to  frequently  discontinue  milk  entirely.  At  such  times 
the  use  of  the  milk-foods — such  as  Nestle's  food — has 
proved  very  beneficial.  When  diluting  milk  with  cereals 
like  barley-water,  rice-water,  sago-water,  flour-ball  and 
water,  it  is  always  better  to  dextrinize  the  diluents.  This 
dextrinization  has  a  decided  effect  on  the  casein,  inasmuch 
as  it  splits  up  the  curd,  rendering  it  finely  flocculent  as 
it  is  found  in  human  milk,  and  it  is  especially  indicated 
in  the  period  of  weaning  after  the  stomach  has  been  ac- 
customed to  breast-milk  and  is  suddenly  forced  to  digest 
cows'  milk  containing  a  more  rubbery  and  heavier  casein, 
or  curd. 


FEEDING  AFTER  WEANING. 


87 


Diet  After  the  Period  of  "Weaning. 

The  following  dietary,  one  of  each  course,  is  to  be 
given  to  a  child  one  and  a  half  to  three  years  old : — 

breakfast,  7  to  8  a.m. 

"  Sliced  apple  with  cream. 
Baked  apple  or  apple-sauce. 
Sliced  banana  with  cream. 
1.  Fruits    ^  Sliced  peaches  with  cream. 
Oranges. 
Fleshy  prunes. 
Grapes. 
Hominy. 
Farina. 
Oatmeal. 
Cream  of  wheat. 
Germea. 

Indian  (or  corn)  meal  pudding. 
Wheaten  grit. 
A  soft-boiled  egg. 
A  scrambled  egg. 

4.  Water,  cocoa,  or  chocolate  to  drink. 

5.  Toast  and  butter,  wheat-broad  and  butter,  or  grape- 
jelly- 

NOON    MEAL,    12    TO    1    P.M. 

1.  Soup  made  with  lentils  or  split  peas,  meat,  and 
vegetables,  but  not  highly  seasoned.  Thicken  soup  by 
adding  either  sago,  farina,  barley,  or  rice.  The  last  should 
be  omitted  if  severe  constipation  exists. 

Broiled  fish;  white  meat  only. 

Raw  scraped  steak. 

Broiled  top  sirloin. 
j    Broiled  tenderloin. 
|    Lamb  chops. 
^  Breast  of  chicken. 


2.  Cereals 


3.  Eggs 


INFANT-FEEDING. 


Spinach. 
Mashed  potato. 
Baked  potato. 
Stewed  corn. 

Mashed  peas  (without  skins). 
[  Cauliflower. 

4.  If  the  appetite  warrants  it,  some  fruit  mentioned 
in  the  breakfast  list  may  be  given. 


3.  Vegetables  <{ 
l 

I 


EVENING    MEAL    (LIGHT)    5.30    TO    6.30    P.M. 

[  Crackers  and  a  bowl  of  milk. 

T        ,  !  Bread  and  a  bowl  of  milk. 

Luncheon  <    ~     ,      ,        ,  ,  „       .,, 

j  Custard  and  a  glass  01  milk. 

[  Junket  and  a  glass  of  milk. 

f  Cornstarch. 
j  Tapioca. 
2.  Puddings   <{  Rice. 
Farina. 
Zwieback. 
Oysters  or  fruit. 


CHAPTER  Xni. 

Management  of  "Woman's  Nipples. 

the  management  oe  the  nipples  before  the 
baby  is  born. 

It  is  very  important  during  the  last  few  months  of 
pregnancy  to  devote  considerable  time  and  attention  to 
the  condition  of  the  nipples.  If  these  be  found  long 
and  round,  well  projecting,  then  it  is  advisable  to  try  to 
harden  them,  because  the  irritation  from  the  child  will 
cause  considerable  trouble  unless  we  seek  to  prevent  this. 


Fig.  15. — Nipple-shield  for  Relief  of  Tender  Nipples. 

For  this  purpose  wash,  in  winter,  with  lukewarm  water 
to  which  some  alcohol  has  been  added  (2  -  teaspoonf uls 
of  alcohol  to  a  cup  of  lukewarm  water).  In  summer  cold 
water  will  be  found  more  agreeable,  using  the  same  quan- 
tity of  alcohol.  If  the  nipples  are  very  small  and  flat, 
and  do  not  protrude  properly,  then  suction  by  means  of 
a  breast-pump,  applied  directly  over  the  breast,  will  draw 
them  out.  In  some  instances  an  ordinary  clay  pipe 
which  has  a  smooth  bowl,  the  bowl  to  be  laid  over  the 

(89) 


90  INFANT-FEEDING. 

nipple  and  the  stem  to  be  sucked  or  drawn,  is  saticfac- 
tory.  This  is  to  be  repeated  every  few  days.  A  few 
minutes  of  drawing  out  will  suffice  until  the  nipples  are 
sufficiently  prominent.  Biedert22  gives  the  following 
prescription  for  hardening  the  nipples: — 

Tannic  acid 1  teaspoonful. 

Red  wine   8  ounces. 

If  red  wine  is  not  handy,  then  substitute  brandy  in 

its  stead.  This  is  to  be  applied  after  thorough  washing 

with  soap  and  water,  and  removing  crusts,  if  they  are 
present. 

TENDER    NIPPLES. 

If,  while  nursing,  the  nipples  crack  and  blood  oozes 
from  them,  or  if,  from  irritation  of  the  child's  gums 
biting  them,  the  nipple  is  sore,  then  it  is  a  good  plan  to 
allow  the  child  to  nurse  through  a  nipple-shield.  (See 
Fig.  15.) 

Nipple-shields  can  be  used  during  the  nursing  act, 
and  immediately  thereafter  the  following  salve  can  be 
smeared  on  the  nipples: — 

R  Zinc  oxide,  1  drachm. 
Vaselin,  1  ounce. — M. 

BREAST-PUMP. 

The  breast-pump  (Figs.  16  and  17)  is  a  valuable  ad- 
dition to  the  nursery.  It  should  be  kept  scrupulously 
clean  by  immersing  it  in  boiling  water  containing  a  pinch 
of  table-salt.  In  drawing  a  specimen  of  breast-milk  for  a 
chemical  examination  the  breast-pump  is  very  useful.  If 
an  infant  is  ill  and  refuses  the  breast, — as,  for  example, 
if  it  has  rhinitis  or  cold  in  the  head,  nasal  obstruction, 
preventing  it  from  breathing  while  the  nipple  is  in  its 
mouth, — it  generally  will  take  the  breast  and  immediately 


22  "Kinderernaehrung,"  fourth  edition,  1900,  page  110. 


BREAST-PUMP. 


91 


let  go  of  it  again.  If  the  breast-pump  is  properly  applied, 
and  the  required  quantity  of  milk  drawn  off,  the  infant 
can  frequently  be  fed  slowly  with  a  spoon. 


Fig.  16. — Breast-pump. 

In  a  serious  condition, — as,  for  example,  in  a  severe 
case  of  pneumonia  with  loss  of  appetite, — the  life  of  the 
child  may  depend  on  forced  feeding.     This  will  be  de- 


Fig.  17. — Breast-pump. 

scribed  in  the  section  on  "Gavage."  It  is  very  important 
to  have  the  cup  or  any  other  receptacle  into  which  we 
draw  the  breast-milk  properly  sterilized;  Otherwise  the 
breast-milk  will  be  infected  in  the  same  manner  as  has 
been  described  in  detail  in  the  sections  on  "Cows'  Milk" 
and  "Bottle-feeding." 


CHAPTEE  XIV. 

Infant's  "Weight. 

When  a  child  develops  normally,  at  either  breast- 
or  bottle-  feeding,  then  it  increases  from  6  to  8  ounces 
each  week  for  the  first  two  or  three  months.  This  gain 
is  slightly  lessened  toward  the  end  of  the  fifth  or  sixth 
month;  but  if  a  child  thrives,  then  its  gain,  be  it  ever 
so  small,  must  be  steady  from  week  to  week.  We  have 
distinct  data  on  which  to  base  our  calculations,  and  any 
variation  from  the  normal  should  be  carefully  investi- 
gated. If  a  child  is  breast-fed,  and  suddenly  ceases  to 
gain  in  weight,  then  a  chemical  examination  of  the  breast- 
milk  is  imperative  to  know  just  what  ingredient  is  want- 
ing. If  the  child  is  bottle-fed,  and  the  weight  does  not 
increase,  then  the  formula  is  improper  and  frequently  the 
addition  of  a  larger  quantity,  or  sometimes  the  changing 
of  the  quality, — as,  for  example,  several  ounces  of  cream 
instead  of  several  ounces  of  milk, — will  give  the  baby  the 
requisite  amount  of  food. 


Table  Showing  the  Gain  in  a  Healthy  Infant 
Fed  at  the  Breast. 

ISTormal    weight    at    birth,       Gain  at  the  end  of  the  first 


7  lb. 


week,  ISTone. 


Weight  when  2  weeks  old,       Gain  at  end  of   2   weeks, 

7  lb.   6  oz. 
Weight  when  3  weeks  old, 

7  lb.  14  oz. 
Weight  when  4  weeks  old, 

8  lb.   6  oz. 

(92) 


6  oz. 
Gain  at  end   of  3   weeks, 

8  oz. 
Gain   at   end  of  4  weeks, 

8  oz. 


infant's  weight.  93 

The  vital  factor  is  certainly  the  general  condition 
of  the  infant,  whether  it  is  bright  and  playful,  sleeps 
quietly,  and  the  condition  of  its  stools.  "When  the  latter 
are  normal  as  to  color  and  frequency,  then  we  may  be 
sure  that  the  baby  is  thriving. 

During  the  second  month  the  infant  should  gain 
about  8  ounces  per  week;  roughly  speaking,  an  ounce 
per  day  is  a  good  average. 

During  the  third  month  a  child  should  gain  an  ounce 
per  day,  or  about  2  pounds  per  month. 

After  the  third  month,  an  infant  usually  gains  about 
3  to  4  ounces  per  week;  so  that  if  a  child  has  doubled 
its  weight  at  the  end  of  the  fifth  month,  such  a  child 
should  be  considered  normal,  if  the  other  conditions 
warrant  such  an  opinion.  An  infant  should  weigh  three 
times  its  weight  at  birth  by  the  end  of  its  first  year. 

Taking  seven  pounds  as  the  average  weight  for  an 
infant  at  birth,  it  should  weigh  14  pounds  at  the  end  of 
five  months  and  21  pounds  at  the  end  of  its  first  year. 

Weighing  Immediately  After  Nursing  to  Determine 
the  Quantity  of  Milk  an  Infant  has  Taken.  —  When 
scanty  milk-supply  is  suspected  in  either  the  nursing 
mother  or  in  a  wet-nurse,  then  we  can,  in  some  instances, 
resort  to  weighing  immediately  after  the  baby  has  nursed. 
It  is  understood  that  the  child  must  be  weighed  both 
immediately  before  nursing  and  then  immediately  after 
nursing.  The  difference  in  weight  is  the  amount  of  milk 
swallowed. 

"While  this  may  serve  in  some  cases,  the  author  has 
not  found  it  very  practical,  and  cannot  recommend  it, 
excepting  in  rare  instances. 

It  is  well  known  that  an  infant  whose  stomach  is 
filled  requires  rest  after  nursing,  and  the  less  it  is 
handled  the  less  is  the  chance  for  expelling  its  food. 
Thus,  my  advice  is  not  to  handle  or  fumble  with  a  child 
after  nursing,  but  rather  aid  Nature  in  resting  an  infant 
than  to  try  to  provoke  vomiting  by  unnecessary  handling. 


94 


INEANT-FEED1NG. 


Difference  in  Weight  Before  and  Immediately  After 
Nursing. — An  infant  should  weigh,  if  under  3  months 


Fig.  18. 


old,  3  ounces  more  after  nursing,  and  in  older  children, 
5  to  6  months,  it  should  weigh  at  least  6  ounces  more 


after  suckling. 


WEIGHT-CHART   FOR   AN   INFANT. 


95 


Weight-chart  for  an  Infant. 


Week 
after 
Birth. 

Date 
of 
Weigh- 
ing. 

Weight 

of 
Child 
with 

Clothes 

Weight 

of 
Clothes 

Body- 
weight 

Kind  of 
Food  ;  Quan- 
tity and 
Frequency 
of  Feeding. 

Stools 

On  the 
birthday. 
After 

1  week .  . 

2  weeks  . 

3  weeks  . 

4  weeks  . 

After 

5  weeks  . 

6  weeks  . 

7  weeks  . 

8  weeks  . 

After 
9  weeks  . 

10  weeks  . 

11  weeks  . 

12  weeks  . 

After 

13  weeks  . 

14  weeks  . 

15  weeks  . 

16  weeks  . 

After 

17  weeks  . 

18  weeks  . 

19  weeks  . 

20  weeks  . 

After 

21  weeks  . 

22  weeks  . 

23  weeks  . 

24  weeks  . 

After 

7  months. 

8  months. 

9  months. 

10  months. 

11  months. 

12  months. 

96 


INFANT-FEEDING. 


Properties  op  Human  Milk. 


Appearance. 
Specific  Gravity. 

Reaction. 
On  Boiling. 
Coagulates. 


Bluish,  semitransparent,  no  odor,  sweetish. 

1.26  to  1.36. 

Amphoteric,  relation  of  alkalinity  and  acid- 
ity as  3  to  1. 

Does  not  coagulate,  and  forms  a  very  thin, 
hardly-perceptible  skin. 

At     ordinary    temperature     after    several 
hours. 


Coagulates  on  addi- 
tion of  Lab-fer- 
ment. 


Coagulates  imperfectly  in  small  isolated 
flakes,  which  do  not  precipitate  as  a  uni- 
form coagulum. 


Fat. 


Yellowish  white,  resembling  cow-butter. 
Specific  gravity  at  15°  C,  0.966.  Melts 
at  34°  C. 


Varieties  of  Fat. 


Butyrin,  palmitin,  stearin,  olein,  myristin, 
caproin. 


Behavior  of  Various  S  Few  volatile  acids.    More  than  half  of  the 
Acids.  (       non-volatile  consist  of  oleic  acid. 


Milk-plasma   Casein. 


Composition  of  Albu- 
minoids. 


Difficult  to  precipitate  with  acids  and  salts. 
The  precipitate  redissolves  in  excess  of 
acids.     During  pepsin  digestion  there  is 
(_      no  pseudonuclein  produced. 

Lactalbumin  and  lactoglobin;    relation  of 

casein  to  albumin,  0.5  to  1.2  or  1  to  2.4; 

of  the  1.3  per  cent,  albumin,  there  are  64 

parts  of  casein,  and  37  parts  of  globulin 

I.      and  albumin. 


Solids. 


Less  solids  than  in  cows'  milk,  especially 
CaO— P2Os. 


Quantitative  Analy-rWater8741.   albuminoids,  2.29;  fat,  3.78; 


sis,    according    to 
Soxhlet 


milk-sugar,  6.21;    solids,  0.31. 


Bacteria. 


Usually  sterile,  rarely  staphylococcus  albua 
and  aureus. 


PROPERTIES    OF    COWS     MILK. 


97 


Appearance. 
Specific  Gravity. 

Reaction. 

On  Boiling. 

Coagulates. 


Properties  of  Cows'  Milk. 

i  Opaque  white  or  whitish  yellow,  in  thin 
layers  bluish  white,  slight  odor,  faintly 
sweet. 

1.28  to  1.36. 

{Amphoteric;  relation  between  alkalinity 
and  acidity,  2  to  1;  Soxhlet  maintains 
that  cows'  milk  contains  three  times  the 
acidity  of  human  milk. 

f  Does  not  coagulate  and  forms  a  skin  con- 
\      taining  casein  and  lime-salts. 

{Coagulates  very  soon,  owing  to  lactic-acid 
formation. 


Coagulates  on  addi- 
tion of  Lab-fer- 
ment. 

Fat. 


Varieties  of  Fat. 


Behavior  of  Various 
Acids. 


Coagulates  to  a  solid  mass  at  body-tem- 
perature, from  which  a  yellowish  fluid 
can  be  expressed. 


Yellowish-white  mass. 
0.949  to  0.996. 


Sp.  gr.  at  15°  O, 


Milk-plasma  Casein. 


Composition  of  Albu- 
minoids. 


Solids. 

Quantitative  Analy- 
sis, according  to 
Soxhlet. 

Bacteria. 


r 


Palmitin,  olein,  stearin,  myristin,  caprilin, 
caprin,  caproin,  butyrin,  laurin,  lecithin, 
cholesterin,  and  yellow  coloring  matter. 

Volatile  fatty  acids,   about  70  per  cent.; 
•  not  volatile,  0.3  to  0.4  per  cent,  of  oleic; 
the  remainder  consists  of  palmitic  and 
stearic  chiefly. 

Easy  to  precipitate  with  acids  and  salts; 
excess  of  acid  does  not  dissolve;  belongs 
to  the  nucleo-albumin  group. 

Less  lactalbumin  and  globin;  the  largest 
portion  of  the  albuminoids  is  casein. 
Relation  of  casein  to  albumin,  0.3  to  3.0, 
or  1  to  10. 

Cows'  milk  contains  more  solids  than  hu- 
man milk. 

Water,  87.17;  albuminoids,  3.55;  fat,  3.69; 
milk-sugar,  4.88;    solids,  0.71. 

Contains  all  milk  bacteria,  frequently  also 
pathogenic  bacteria,  as  typhoid,  diph- 
theria, and  tubercle  bacilli,  etc. 


CHAPTER  XV. 


Raw  Cows'  Milk. 


The  ideal  cows'  milk  is  clean,  raw  milk.  By  this  is 
meant  milk  free  from  all  possible  contamination.  Such 
milk  should  he  obtained  from  a  stable  having  all  modern 
hygienic  surroundings.  If  greater  attention  were  be- 
stowed on  the  condition  of  the  cow,  the  cow's  udder,  the 
stable,  the  bucket,  the  hands  of  the  milker,  then  less  ster- 
ilization and  pasteurization  would  be  necessary.  For  let 
it  be  distinctly  understood  that  certain  chemical  changes 
are  brought  about  in  milk  when  it  is  steamed,  be  it  in 
the  process  of  sterilization  or  pasteurization.  Neither 
pasteurization  nor  sterilization  adds  to  the  digestibility  of 
milk.  Indeed,  clinical  experience  has  demonstrated  the 
fact  that  raw  milk,  known  in  some  places  as  certified  milk, 
in  the  milk-laboratories  in  New  York  City  as  guaranteed 
milk,  is  more  easily  assimilated,  as  proved  by  the  condi- 
tion of  the  stools  as  well  as  the  gastric  digestion. 

Nature  has  given  us  a  good  example  of  how  milk 
should  be  fed  to  an  infant.  Breast-milk  is  certainly  raw 
milk,  and  is  served  to  the  infant  at  the  temperature  of 
the  body.  Not  only  does  boiling  or  steaming  milk  pro- 
duce chemical  changes  in  the  albuminoids,  but  it  renders 
the  process  of  digestion  much  more  difficult,  and  thus  it 
is  that  most  infants  taking  boiled  milk  suffer  with  con- 
stipation. This  is  not  so,  however,  in  the  case  of  infants 
fed  on  raw  milk. 

When  sterilized  milk  or  pasteurized  milk  is  found 
to  disagree  with  children,  raw  milk  may  sometimes  be 
easily  assimilated.  Thus  it  will  be  found  that,  while 
boiled  milk  or  sterilized  or  pasteurized  milk,  given  either 
whole  or  with  its  proper  dilution  to  suit  the  various  ages, 
(98) 


RAW  COWS'  MILK.  99 

will  provoke  constipation,  by  substituting  raw  milk  in- 
stead of  the  heated  milk  the  same  will  be  more  easily 
assimilated.  The  author  has  frequently  noted  decided 
antiscorbutic  properties  in  fresh  raw  milk.  In  children 
with  pronounced  rickets,  and  even  scurvy,  the  withdrawal 
of  sterilized  or  other  milk  and  the  substitution  of  fresh 
raw  milk  will  work  surprising  changes. 

Biedert,  in  his  fourth  edition  of  1900,  page  184, 
states  that  he  has  followed  Escherich  and  Epstein,  who 
recommend  giving  full  milk  to  children  at  birth.  In 
Erance  Budin  and  H.  de  Rothschild,  and  more  recently 
E.  Schlesinger,  in  Germany,  have  given  undiluted  milk 
to  both  sick  and  well  children  as  a  substitute  for  breast- 
milk.  Biedert  claims  to  have  seen  good  results  in  some 
instances,  but  cannot  recommend  whole  milk,  as  a  rule, 
for  feeding  children.  Marfan,  another  advocate  of  pure- 
milk  feeding,  believes  that  milk  should  be  diluted  until 
the  fourth  or  fifth  month,  but  later  he  advises  pure-milk 
feeding.  Schlesinger,  of  Breslau,  while  giving  pure 
milk  gives  a  longer  interval  between  the  meals.  That 
the  greatest  possible  success  is  not  achieved  by  this  method 
of  feeding  in  France  can  be  judged  by  the  statement  of 
Marfan  while  discussing  the  subject  of  athrepsia.  He 
says:  "N'a  jamais  vu  V athrepsie  confirmee  se  terminer 
favor 'dblementP  Thus  it  seems  that  even  we  have  much 
better  results  than  the  French,  for  there  are  certainly  a 
great  many  children  who  can  and  will  digest  a  diluted 
milk,  and  thin  milk-  and  cream-  mixtures,  as  shown  by 
their  stools,  their  sleep,  and  their  increase  in  weight. 
These  same  children  with  enfeebled  digestive  functions 
will  invariably  show  gastric  disturbances, — such  as  vom- 
iting, colic,  constipation  or  diarrhoea,  restlessness,  sleep- 
lessness,— and  will  cry  continually;  besides,  they  do  not 
increase  in  weight.  This  method  of  feeding  has  been 
tried  over'  and  over  again,  and  we  are  compelled  to  dis- 
continue the  heavier  food,  consisting  of  pure  milk,  and 
to  substitute  a  light  food,  consisting  of  diluted  milk. 


100  infant-feeding. 

Fkesh  Raw  Milk. 

Just  as  the  medical  profession,  and  to  some  extent 
the  laity,  have  become  thoroughly  impressed  with  the 
idea  that  milk  should  be  boiled  before  being  used,  to 
insure  the  destruction  of  the  microbes  which  it  contains, 
Dr.  Freudenreich  comes  forward  with  a  series  of  experi- 
ments, by  which  he  claims  to  prove  that  fresh  raw  milk 
possesses  remarkable  germicidal  properties.  According  to 
his  experiments,  the  bacillus  of  cholera,  when  put  into 
fresh  cows'  milk,  dies  in  an  hour,  the  bacillus  of  typhoid 
fever  succumbs  at  the  end  of  twenty-four  hours,  while 
other  germs  die  at  the  end  of  varying  periods. 

Milk  which  has  been  exposed  to  a  temperature  of 
131°  F.  loses  its  germicidal  properties.  Milk  which  is 
four  or  five  days  old  is  also  devoid  of  microbe-killing 
power.23 

Raw-Milk  Assimilation. 

Vasilieff,24  in  an  inaugural  thesis  of  1889,  in  St. 
Petersburg,  details  experiments  made  on  six  healthy  in- 
dividuals, varying  from  18  to  23  years  of  age,  restrict- 
ing them  for  three  days  to  a  diet  of  fresh  milk,  and  then 
for  the  three  days  following  to  boiled  milk.  The  author 
claims  that  his  experiments  have  proved  that  the  assimi- 
lation of  the  nitrogenous  principles  of  the  boiled  milk  is 
considerably  less  than  of  fresh  milk,  although  the  differ- 
ence is  less  marked  than  in  the  case  of  the  fats.  Never- 
theless the  feces  contain  considerably  more  fatty  acids 
after  the  administration  of  boiled  milk  than  after  the  use 
of  fresh  milk.  He  therefore  concludes  that  the  nutritive 
value  of  boiled  milk  is  much  inferior  to  that  of  fresh 
milk.     He  explains  these  differences  by  the  hypothesis, 


"Bacteriological  World,  December,  1891;  Journal  of  the  Ameri- 
can Medical  Association,  February  27,  1892. 

24  Journal  de  Medecine,  May  4,  1890;  Therapeutic  Gazette,  June 
16,  1890. 


SCURVY.  101 

first  advanced  by  Schmidt,  that,  by  boiling,  a  part  of  the 
casein  in  cows'  milk  is  transformed  into  hemialbuminose. 


Scukvt. 

A  paper  on  "The  Uses  and  Prospects  of  Pathology," 
delivered  at  the  opening  of  the  Section  in  Pathology  at 
the  recent  annual  meeting  of  the  British  Medical  Asso- 
ciation, by  Dr.  W.  Howship  Dickinson,  senior  physician 
and  lecturer  on  medicine  at  St.  George's  Hospital,  states 
that  a  disease  which  presents  itself  as  of  chemical  origin, 
if  one  due  almost  certainly  to  a  specific  deficiency  in  the 
constituents  of  the  food  may  be  so  regarded,  is  scurvy,  of 
which  the  chemical  secret  has  apparently  been  so  readily 
exposed  that  the  chemical  antidote  ought  to  be  almost 
within  our  grasp.  The  conditions  which  give  rise  to  sea- 
scurvy  are  generally  known.  It  is  not  probably  as  widely 
recognized  that  scorbutic  affections  are  so  common  on 
shore,  among  infants  brought  up  by  hand,  that  this  form 
of  land-scurvy  is  scarcely  less  important.  It  is  to  be  at- 
tributed to  the  exclusion  of  fresh  milk  by  various  arti- 
ficial preparations  used  in  its  stead.  Not  that  these  prep- 
arations are  in  themselves  injurious,  but  they  are  insuffi- 
cient. 

Milk  in  its  fresh  state,  and  of  good  quality,  whether 
from  biped  or  quadruped,  is  antiscorbutic;  preparations 
or  sophistications  of  it  are  not  so,  or  not  so  to  a  sufficient 
extent.  Scorbutic  hematuria  and  scurvy-rickets  are  but 
too  frequent  consequences  of  this  substitution.  We  know 
the  broad  result,  which  is  enough  for  practice,  but  we  do 
not  know  the  isolated  want.  What  does  fresh  milk  con- 
tain which  is  so  essential  and  so  difficult  to  preserve?  We 
no  more  know  this  than  what  there  is  in  lemon-juice  to 
be  antiscorbutic,  while  neither  citric  acid,  nor  potash  are 
so.  The  problem  is  attractive,  like  a  puzzle;  some  day 
it  will  be  solved,  and  then  we  shall  wonder  why  it  was 
not  solved  before. 


102 


INFANT-FEEDING. 


Raw  Meat:    its  Beneficial  Effect  Experimen- 
tally Proved. 

Bichet  and  Hericourt  announced,  at  the  meeting  of 
the  Paris  Societe  de  Biologie,  June  2d,  that  they  inocu- 
lated a  number  of  dogs  with  tuberculosis  more  than  six 


Fig.  19. 


Fig.  20. 

months  ago.  One-third  were  fed  with  ordinary  food,  and 
all  died  in  three  or  four  weeks;  another  set  with  cooked 
meat,  with  about  the  same  results,  while  the  third  group 
was  fed  exclusively  with  the  raw  meat,  and  all  have  sur- 
vived to  date  and  are  in  good  health. 


infant-feeding.  103 

Raw  Muscle- juice  Possesses  Antitoxic  Properties. 

A.  Sicarcl25  says  the  effect  of  "zomotherapy"  —  as 
Eichet  calls  his  experiments  with  328  dogs  inoculated 
with  tuberculosis  and  then  fed  on  raw  meat — indicates 
that  the  raw  muscle-juice  has  a  specific  antitoxic  power 
in  regard  to  the  tubercle  bacillus.  The  dogs  survived, 
on  an  average,  300  days,  and  some  for  two  and  a  half 
years,  while  the  control  animals  all  readily  succumbed. 
Sicard  discusses  the  various  theories  advanced  to  explain 
these  facts,  and  suggests  that  it  would  be  interesting  to 
determine  whether  other  food-elements  (codliver-oil,  for 
instance),  administered  to  dogs  and  guinea-pigs  in  suffi- 
cient amounts,  would  have  an  inhibiting  action  on  the 
evolution  of  experimental  bacillosis;  also  whether  forced 
ingestion  of  raw  or  dried  meat  would  transform  the  cel- 
lular or  humoral  medium  in  animals  and  render  them 
refractory  to  infection. 

Infant-feeding.2  6 

It  is  impossible  to  go  over  the  broad  domain  of  arti- 
ficial feeding  in  the  time  usually  allotted  to  a  discussion 
and  do  justice  to  all  the  interesting  papers  presented. 
Let  me,  therefore,  give  you  in  brief  what  would  be  my 
personal  views  based  on  clinical  experience. 

My  first  proposition  in  hand-feeding  is:  Secure  the 
best  possible  cows'  milk  from  a  reliable  dairy.  The  hy- 
gienic condition  of  the  cows'  stable  should  be  in  accord 
with  modern  sanitary  laws;  so  that  the  principle  of  steril- 
ization is  applied  to  everything  from  the  stable,  to  the  cow, 
to  the  milker's  hands,  and  to  all  utensils  used  in  milking 
and  transportation,  exactly  as  given  by  Professor  Bagin- 
sky  in  his  paper,  which  I  had  the  honor  to  read  at  the 


25Presse  Medicale   (Paris),  June  13th. 

26  Discussion  on  infant-feeding,  Academy  of  Medicine,  October 
18,  1900,  by  Louis  Fischer,  M.D.  Archives  of  Pediatrics,  January, 
1901. 


104  INFANT-FEEDING. 

meeting  of  the  Section  on  Diseases  of  Children  at  Atlantic 
City,  June,  1900.  Summing  up,  then,  asepsis — which  is 
really  nothing  but  absolute  cleanliness — should  be  rigidly 
enforced. 

Second  Proposition.  —  Imitate  Nature  in  feeding, 
using  raw  milk.  In  this  way  we  copy  from  Nature  just 
what  she  has  ordained  for  woman  to  feed,  for  it  must  be 
admitted  that  breast-milk  (woman's)  is  raw  milk.  It  is 
neither  boiled,  sterilized,  nor  pasteurized.  When  the  pre- 
cautions mentioned  in  my  first  proposition  are  carried  out, 
there  is  no  risk  of  infection. 

Do  we  ever  stop  to  think  how  many  millions  of  mi- 
crobes lie  dormant  in  the  gastro-intestinal  canal  ready  to 
reinfect  the  sterilized  milk?  My  plan  is  to  give  pure  milk 
(properly  diluted  or  pure)  if  the  age  warrants,  and  merely 
warm  it  immediately  before  feeding  it  to  the  infant — 
temperature  of  100°  F. 

We  know  that  a  great  many  children  fed  on  sterilized 
milk  develop  scurvy.  The  same  is  true  of  children  fed 
on  boiled  milk.  The  reason  is,  Rundlett  so  ably  says: 
"Changes  take  place  not  in  the  albumin,  fat,  nor  sugar, 
but  in  the  albuminate  of  iron,  phosphorus,  and  possibly 
in  the  fluorin  vital  changes  take  place.  These  albumi- 
noids are  certainly  in  the  milk,  derived,  as  it  is,  from  tis- 
sues that  contain  them,  and  are  present  in  a  vitalized 
form,  as  proteids." 

On  boiling,  the  change  taking  place  is  simply  due 
to  the  coagulation  of  the  globulin,  or  proteid  molecule, 
which  splits  away  from  the  inorganic  molecule  and  thus 
renders  it,  as  to  the  iron  and  fluorin,  unabsorbable,  and, 
as  to  the  phosphatic  molecule,  unassimilable.  This  is  the 
change  that  is  so  vital,  and  this  only  takes  place  when 
milk  is  boiled. 

It  is  evident  that  children  require  phosphatic  and 
ferric  proteids  in  a  living  form,  which  are  only  contained 
in  raw  milk. 

Cheadle  says  that  phosphate  of  lime  is  necessary  to 


INFANT-FEEDING.  105 

every  tissue;  no  cell-growth  can  go  on  without  earthy 
phosphates;  even  the  lowest  form  of  life — such  as  fungi 
and  bacteria — cannot  grow  if  deprived  of  them.  These 
salts  of  lime  and  magnesia  are  especially  called  for  in 
the  development  of  the  bony  structures. 

Avoidance  of  Scurvy. — Since  clinical  experience  has 
demonstrated  that  the  prolonged  use  of  sterilized  and 
boiled  milk  will  produce  scurvy,  and  that  improvement 
is  immediately  noted  when  raw  milk  is  given  or  raw 
muscle-juice  (beef-juice)  or  raw  white  of  egg,  added  to 
fresh  fruit-juices,  does  it  not  seem  more  plausible  to  com- 
mence feeding  at  once  with  raw  milk  rather  than  after 
scurvy  or  rickets  is  developed? 

There  is  a  certain  deadness,  or,  to  put  it  differently, 
absence  of  freshness,  in  milk  that  has  been  boiled  or  ster- 
ilized, which  causes  disease  in  the  infant  just  as  the  ab- 
sence of  fresh  meats  and  green  vegetables  is  known  to 
cause  scurvy  in  the  adult. 

GENEEAL  EULES  FOE  FEEDING  INFANTS. 

Each  child  is  a  law  unto  itself,  and  its  individual 
wants  must  be  studied.  One  child  will  gain  on  the  same 
mixture  on  which  another  will  lose  weight.  The  proof 
of  the  proper  assimilation  of  food  in  any  and  every  child 
will  be  the  following: — 

The  infant  must  appear  satisfied  after  taking  its  bottle. 
There  should  be  no  vomiting  nor  severe  colicky  pains. 

The  bowels  must  move  (unaided)  at  least  once  or 
twice  in  twenty-four  hours.  The  stools  should  be  yellow- 
ish white  and  medium  soft. 

The  infant  should  sleep  from  four  to  eight  hours  at 
one  time  during  the  night. 

The  weight  must  be  taken  regularly  once  a  week.  If 
an  infant  thrives  it  should  gain  at  least  from  6  to  8  ounces 
every  week.  When  the  child's  weight  shows  no  increase, 
then  study  the  reason,  and  by  all  means  change  the  food; 
give  more  substantial  food. 


10G  INFANT-FEEDING. 

SUBSTITUTE    FOE    MILK    IN    DISEASES    OF    STOMACH 
AND    INTESTINES. 

"When  milk  disagrees  and  the  infant's  stomach  will 
not  tolerate  the  same,  and  vomiting  is  provoked,  or  when 
gastro-intestinal  trouble  arises,  then  milk  must  be  stopped. 
At  such  times  I  have  seen  very  good  results  follow  the 
use  of  almond-milk  (see  "Dietary"). 

Dextrinization  is  successful  in  children  having  sub- 
normal gastric  digestion.  The  author  does  not  advise  the 
dextrinization  of  food  for  healthy  children,  but  only  in 
feeble,  ill-nourished,  and  weakened  conditions. 


CHAPTEK  XVI. 

Cows'  Milk. 

Hammersten27  gives  Konig's  analysis  of  milk  in  a 
tlionsancl  parts  as  follows: — 

Water    874.2 

Solids  125.8 

Fat    36.5 

Sugar   48.1 

Salt 7.1 

Proteid  (casein,  28.8;  albumin,  5.3) 34.1 

Prof.  A.  Baginsky28  gives  the  following  analysis  of 
cows'  milk,  made  at  the  Kaiser  and  Kaiserin  Friedrich 
Hospital,  Berlin: — 

Water    87.60 

Solids  12.38 

In  one  hundred  parts. 

The  solids  consist  of: — 

Casein  and  albumin 3.65 

Butter    3.11 

Milk-sugar    4.54 

Inorganic  salts   1-08 

Besides  large  amounts  of  potassium  and  potassium 
salts  and  small  quantities  of  iron. 

COMPOSITION,    VARIATION,    AND    PRODUCTION. 

Milk  of  all  animals,  roughly  speaking,  is  composed 
of  the  same  ingredients,  but  an  analysis  of  milk  is  apt 
to  be  very  misleading,  as  it  does  not  show  the  physical 

27  "Physiological  Chemistry." 

28  "Diseases  of  Children,"  1899,  page  32. 

(107) 


108  INFANT-FEEDING. 

condition  of  the  milk,  which  is  the  important  thing  to 
know  from  the  physician's  standpoint. 

The  general  ingredients  of  milk  are  fat,  sugar,  albu- 
min, casein,  mucin,  salts,  and  water.  These  ingredients 
vary  greatly  in  quantity  from  day  to  day  and  from  milk- 


Fig.  21. — Cows'  Milk,  showing  Fat-globules.     Magnified 
330  Diameters. 

ing  to  milking.  An  average  analysis  of  woman's  milk 
does  not  show  what  an  infant  is  getting,  by  any  means, 
for  the  composition  of  the  milk  depends  on  the  food  and 
health  of  the  mother  and  the  frequency  of  nursing. 

It  seems  to  be  pretty  well  settled  that  the  fat  in 
woman's  milk  usually  varies  between  3  and  5  per  cent., 
the  sugar  between  4  and  8  per  cent.,  proteids  (albumin 


COWS'    MILK.  109 

and  casein)  between  1  and  2  per  cent.,  and  the  ash  be- 
tween 0.2  and  0.4  per  cent.,  the  water  being  about  88 
per  cent.  Wide  extremes  are  met  with;  so  it  is  useless 
to  think  of  woman's  milk  as  of  a  certain  composition. 

Cows'  milk,  which  is  the  only  milk  worth  consider- 
ing in  connection  with  artificial  infant-feeding,  shows 
great  variation  in  composition,  just  as  does  woman's  milk. 
There  is  no  such  thing  as  average  cows'  milk.  It  may 
be  that  the  mixed  milk  of  a  particular  herd  of  cows  will 
run  uniform  in  composition  for  a  long  time,  but  this  is 
because  the  variations  in  the  milk  of  individual  cows 
offset  each  other.  A  difference  of  25  per  cent,  in  the 
amount  of  fat  in  night  and  morning  milk  has  been  no- 
ticed in  the  milk  of  some  cows.  This  is  why  "one  cow's 
milk"  should  not  be  used.  Mixed  milk  of  different  herds 
of  cows  will  vary  between  3  and  5  per  cent,  fat,  4  and 
5  per  cent,  sugar,  3  and  4  1/2  per  cent,  casein  and  albu- 
min, while  the  ash  runs  about  0.7  per  cent,  and  the  water 
about  88  per  cent.,  all  depending  on  the  breed  of  cows 
and  their  food.  Some  breeds  give  large  quantities  of 
milk  poor  in  solids,  while  others  give  smaller  quantities 
of  milk  rich  in  solids. 

As  a  general  rule,  the  shorter  the  interval  between 
milkings,  the  richer  the  milk  is  in  solids.  Dry  food  in- 
creases, and  succulent  decreases  the  quantity  of  solids  in 
the  milk.  Slight  febrile  conditions  increase  the  quantity 
of  fat  and  albumin;  depression  reduces  fat  and  albumin. 
Casein,  sugar,  and  ash  are  the  least  variable  ingredients. 

The  composition  of  the  fat  of  milk  and  the  size  of 
the  fat-globules  vary  with  the  period  of  lactation,  the 
breed  of  cows,  and  the  kind  of  food  used.  Linseedmeal 
is  said  to  make  a  soft,  oily  fat,  while  cottonseedmeal  and 
some  other  foods  make  a  hard  fat.  Small,  hard  fat-glob- 
ules are  noticeable  when  the  animal  becomes  pregnant. 

The  practical  problem  before  the  physician  in  bottle- 
feeding  is  to  prepare  a  food  that  approximates  mothers' 
milk  in  composition  and  physical  properties.    To  get  good 


110  INFANT-FEEDING. 

results  good  cows'  milk  must  be  used,  and  the  physician 
should  know  that  this  can  be  had  anywhere  if  strict  clean- 
liness is  observed  by  the  milkman. 

Aside  from  the  difference  in  composition  between 
cows'  milk  and  woman's  milk,  cows'  milk  often  contains 
lactic  acid  and  other  products  of  bacterial  growth,  which 
may  cause  digestive  disturbance.  The  lactic  acid  is  the 
result  of  the  growth  of  the  lactic  bacteria  that  are  always 
found  in  milk  and  which  get  into  the  milk  from  the  dirt 
in  the  stable. 

Good  milk  can  be  had  by  keeping  the  cows  clean  and 
wiping  the  udders  with  a  damp  cloth  just  before  milking. 
The  first  three  or  four  jets  from  each  teat  should  be 
thrown  away,  as  they  are  always  infected,  and  then  the 
milking  should  be  continued  into  a  clean  pail.  The  milk 
should  then  be  immediately  cooled  to  below  45°  F.,  at 
which  temperature  there  is  little  or  no  growth  of  bac- 
teria. Unless  this  is  done  the  bacteria  that  always  get 
into  the  milk,  no  matter  how  much  care  is  exercised,  will 
grow  rapidly,  and,  after  they  have  had  a  start,  all  the 
care  possible  will  not  repair  the  damage.  Milk  produced 
as  described  has  been  known  to  keep  in  good  condition 
in  summer  in  a  refrigerator  for  three  weeks  and  it  is  not 
at  all  unusual  to  buy  bottled  milk  in  New  York  that  is 
forty-eight  hours  old  that  will  not  redden  litmus-paper. 

Cows'  Food.  —  The  natural  food,  fresh  grass,  is  the 
best;  next  to  this  hay  is  the  best.  The  greater  the  pro- 
portion of  nitrogen  in  the  food,  the  greater  is  the  yield 
of  milk,  the  proportion  of  fat  being  especially  high. 
Feeding  cows  with  brewers'  grain  depreciates  the  quality 
by  lowering  the  total  solids  of  the  milk.  Such  feeding 
is  illegal  in  a  great  many  States,  particularly  Wisconsin. 
Beets,  carrots,  and  swedes  increase  the  proportion  of  milk- 
sugar. 

Average  Percentage  of  Fat. — The  average  percentage 
of  fat  found  is  4  per  cent.  The  Health  Department  does 
not  condemn  milk  having  more  than  3  per  cent,  of  fat. 


TUBERCULIN  REACTION  IN  COWS.  Ill 

The  uniformity  of  milk,  particularly  in  New  York  City, 
is  certainly  due  to  the  extreme  care  and  vigilance  of  the 
Board  of  Health  of  our  city.  It  is  not  surprising  that 
milk  is  so  frequently  adulterated  when  it  is  possible  to 
add  about  20  per  cent,  of  water  or  30  per  cent,  of  skim- 
milk  to  milk  of  average  quality  without  the  resulting 
mixture  falling  below  the  present  requirements. 

Tuberculin  Reaction  in  Cows. 

Conclusions  as  to  the  tuberculin  test,  in  the  Bulletin 
of  the  Massachusetts  Agricultural  College: — 

1.  Tuberculin  furnishes  a  very  delicate  and  reliable 
test,  and  is  the  only  means  by  which  tuberculosis  can  be 
stamped  out. 

2.  A  certain  number  of  sound  cows  will  show  the 
tuberculin  reaction. 

3.  A  certain  number  of  tuberculous  cows  will  not 
show  the  tuberculin  reaction. 

The  Cattle  Commissioners  of  Massachusetts  had,  at 
Brighton,  on  February  15,  1895,  40  cattle  which  they 
had  subjected  to  the  tuberculin  test  and  condemned  as 
tuberculous.  The  figures  of  the  tuberculin  test  were 
carefully  reviewed  at  the  office  of  the  commission  in 
Dorchester,  and  it  was  decided  that  13  of  the  lot  should 
be  killed  on  that  day. 

There  wTere  present  Commissioner  Herrick  and  Dr. 
Lyman,  secretary  of  the  commission ;  Dr.  Burr,  inspector 
for  the  city  of  Boston;  and  Dr.  Way,  acting  in  behalf 
of  the  owners. 

At  the  last  moment  it  was  discovered  that  3  of  the 
cows  had  not  been  appraised  and  10  only  were  killed. 

Two  of  the  10  were  undoubtedly  tuberculous.  Four 
were  pronounced  to  be  so  by  Commissioner  Herrick  and 
Dr.  Lyman,  but  declared  not  to  be  so  by  Dr.  Way.  Their 
organs  were,  therefore,  sent  to  Professor  Whitney,  of 
Harvard  College,  for  microscopical  examination.  In  1  of 
these  4  cows  an  abscess  was  found  in  which  was  a  short 


112  INFANT-FEEDING. 

nail  which  had  apparently  caused  it.  By  the  most  care- 
ful examination  the  commissioners  could  find  no  signs 
of  tuberculosis  in  the  4  remaining  cows,  and  they  were 
accordingly  dressed  and  sold  for  beef.29 

Causes  of  Tuberculous  Diseases  in  Children. 

Dr.  J.  Walter  Carr30  has  made  investigations  as  to 
the  starting-point  of  tuberculous  disease  in  children;  he 
made  post-mortem  examinations  in  120  cases  of  children 
who  died  at  the  Victoria  Hospital,  Chelsea,  Eng.,  of  vari- 
ous forms  of  tuberculosis.  He  concluded  that  in  two- 
thirds  of  the  cases  the  disease  began  in  the  thorax  and 
evidently  was  not  due  to  tuberculous  milk  (that  is,  in- 
fection from  the  food)  and  that  milk  is  by  no  means  a 
frequent  channel  of  infection  as  compared  with  infection 
by  the  lungs.  It  is  often  asserted  that  tuberculous  milk 
causes  the  greater  part  of  deaths  in  children;  even  sum- 
mer diarrhoea,  cerebral  meningitis,  peritonitis,  "consump- 
tion of  the  bowels,"  etc.,  are  laid  to  the  door  of  tubercu- 
lous cows.  The  fallacy  is  that  consumption  (tuberculosis) 
in  children  is  a  generalized  condition;  in  the  adult,  a 
localized  condition.  The  mesenteric  glands  are  often 
affected  in  children,  but  careful  examination  shows  that 
the  starting-place  was  in  the  thorax.  The  point  is,  not 
what  organs  are  affected  at  death,  but  in  what  organ 
the  disease  begins.  Dr.  Carr  says  that  bacilli  are  omni- 
present, and  it  is  impossible  to  keep  a  child  from  contact 
with  them.  The  great  points  in  the  prevention  of  tuber- 
culosis in  children  are  the  maintaining  of  perfect  health 
and  avoiding  respiratory  and  gastro-intestinal  catarrh,  and 
keeping  the  mucous  membrane  healthy. 

Yellowish  Milk. 
Before  and  after  calving  milk  is  yellowish,  due  to 
the  presence  of  small,  yellow  bodies.     Such  milk  is  called 


Spy,  Worcester,  Mass. 
Lancet,  May  12,  1894. 


FROZEN  AND  SOUR  MILK.  113 

colostrum,  and  in  the  case  of  cows  is  unfit  for  human 
consumption. 

Pus-cells  rather  larger  than  the  red  blood-corpuscles, 
granulated,  and  with  a  core  or  irregular  contour,  are 
found,  as  are  blood-corpuscles,  in  the  milk  of  sick  cows. 
They  are  prevented,  as  Soxhlet  has  pointed  out,  from 
coalescing  into  an  oily  film  by  the  condition  of  the  albu- 
min, which  isolates  the  fat-corpuscles  in  its  meshes. 

Frozen  Milk. 

Partial  freezing  of  milk  produces  a  concentration  of 
the  solids  in  the  part  remaining  liquid,  while  the  part 
frozen  is  deficient  in  them.  In  winter,  when  milk  has 
undergone  a  partial  freezing,  great  care  should  be  taken 
to  allow  it  to  thaw  and  then  to  thoroughly  mix  the  same 
before  allowing  it  to  be  sold. 

Sour  Milk. 

"When  milk  stands  for  some  time,  fermentative  changes 
due  to  a  micro-organism — usually  bacillus  acidi  ladici — 
take  place.  This  decomposes  the  milk-sugar,  resulting  in 
the  production  of  lactic  acid,  which  eventually  causes  the 
milk  to  become  sour.  The  change  is  very  largely  depend- 
ent upon  the  time  the  milk  has  been  allowed  to  stand,  and 
more  particularly  upon  the  temperature  of  the  place  in 
which  it  is  kept. 

When  the  fermentative  change  has  resulted  in  the 
production  of  about  0.4  per  cent,  of  lactic  acid,  the  milk 
can  be  distinctly  recognized,  by  the  taste,  to  be  sour. 
When  the  acidity  reaches  0.6  per  cent,  the  milk  curdles, 
and  it  spontaneously  separates  into  a  solid,  known  as  curd, 
which  consists  of  the  fatty  and  proteid  constituents  of  the 
milk,  and  a  clear  liquid  known  as  whey,  which  consists 
essentially  of  a  solution  of  milk-sugar  and  mineral  salts. 
This  same  change  is  brought  about  artificially  when  we 
add  rennet. 


114  infant-feeding. 

Koumiss. 

This  is  a  preparation  of  mares'  or  asses'  milk  in  a 
partly  fermented  condition,  largely  used  in  Russia.  It  is 
prepared  as  follows:  The  milk  is  allowed  to  cool,  and  is 
then  deprived  of  a  part  of  its  cream ;  a  little  yeast  is  then 
added.  This  sets  up  a  slow  fermentation,  the  milk-sugar 
being  converted  into  alcohol  and  lactic  acid.  During  the 
fermentation  the  milk  is  subjected  to  frequent  agitation, 
the  object  of  which  is  to  maintain  in  suspension  the 
casein,  which  has  a  tendency  to  separate  during  the  fer- 
mentation. Koumiss  (called  Kumyss)  is  prepared  in  this 
country  from  cows'  milk.  The  chief  manufacturer  is  Dr. 
E.  P.  Brush,  of  Mt.  Vernon,  ~N.  Y.  Another  preparation 
which  I  have  used  is  known  as  zoolak  and  is  made  by 
Dr.  Dadirrian. 

GlAOTTRDI. 

Giaourdi,  a  food  similar  to  junket  and  very  highly 
nutritious,  has  been  introduced  by  Dr.  A.  Rose,  of  New 
York  City.  It  is  largely  used  in  Greece,  and  is  adapted 
for  subnormal  digestion.  The  author  some  time  ago  used 
this  food  and  noted  good  results  in  a  child  suffering  with 
marked  leucocytosis  following  pneumonia.  It  is  also 
adapted  for  the  convalescent  period,  when  restorative 
foods  are  indicated. 


CHAPTER  XVII. 

Buttermilk  Feeding. 

A  very  elaborate  paper  on  the  subject  of  buttermilk 
feeding,  by  Dr.  Teixeira  de  Mattos,  of  Rotterdam,  has  re- 
cently appeared.31  He  cites  de  Jager,  who  published  a 
paper32  recommending  this  form  of  feeding;  Karger33; 
Houwing34;  and  private  and  public  reports  of  Schloss- 
mann, Heubner,  Soltmann,  Finkelstein,  de  Mattos,  and 
others. 

While  practically  unknown  one  year  ago,  it  is  now 
pushing  its  way  forward.  In  Holland  this  treatment  is 
very  popular. 

Buttermilk  feeding  of  children  is  by  no  means  new, 
having  been  used  in  1790  by  P.  Campert  (cited  by 
Biedert).  Very  little  appears  in  literature  about  this 
article  of  diet  until  in  IS 65  Dr.  Ballot,  of  Holland, 
again  revived  and  recommended  it. 

To  Prepare  the  Food:  Take  1  quart  (liter)  of  buttermilk; 
add  1  even  tablespoonful  of  rice,  wheat,  or  other  flour  desired 
(about  10  to  12  grammes) ;  heat  the  mixture  over  a  small  gas 
fire,  with  constant  stirring,  until  it  has  boiled  up  three  different 
times  (requiring  about  twenty-five  minutes)  ;  then  add  2  or  3 
tablespoonfuls  (about  70  to  90  grammes)  of  cane-sugar  or  beet- 
sugar.  It  is  better  to  use  new  enameled  ware  or  agate  ware 
for  preparing  this  food.  The  food  as  above  prepared  assumes 
a  yellowish  color. 

31  Jalirbuch  fur  Kinderheilkunde,  January,  1902. 

32  Nederlandsch  Tydschrif t  voor  Geneeskundigebladen,  October, 
1895. 

33  "Die  Verdauung  und  assimilation  des  Gesunden  und  Kranken 
Sauglings,  nebst  einer  rationellen  methode  zur  Senglingsernahrung," 
Berlin,  1898. 

3*  Centralblatt  fur  Gyniikologie,  51,  190. 

(115) 


116  INFANT-FEEDING. 

It  is  necessary  to  have  large  corks  for  the  bottle  or  the 
food  coagulates  and  gets  lumpy,  in  which  event  it  would  re- 
quire occasional  shaking  to  bring  the  thickened  portion  to 
the  proper  consistency. 

De  Mattos  reports  a  series  of  cases  in  which  butter- 
milk was  used.  The  bulk  of  these  cases  were  ansemic, 
atrophic  cases  requiring  restorative  treatment.  In  all 
cases  reported  the  weight  was  increased  and  dyspeptic 
symptoms,  when  present,  rapidly  disappeared. 

The  increase  in  weight  noted  by  de  Mattos  was  from 
500  to  TOO  grammes  weekly  in  debilitated  children,  and 
Schlossmann  reports  as  much  as  700  grammes'  increase 
in  six  days. 

Graanboom,  in  his  recent  book  on  "Diseases  of  the 
Digestive  Tract  in  Children"  (1901),  states  that  he  also 
is  very  much  impressed  with  the  value  of  buttermilk  as 
an  infant-food. 

De  Mattos  states  that  children  so  fed  for  a  period  of 
six  to  eight  months  show  signs  of  rickets  or  late  dentition, 
although  they  look  well  and  appear  to  be  well  nourished. 
Whether  or  not  other  methods  are  worse  he  does  not  state. 

Lactic  acid  was  never  found  in  the  urine  of  infants 
fed  either  with  lactic  acid  or  its  salts.  This  series  of 
experiments  was  made  by  de  Mattos,  and  the  results  were 
corroborated  by  Houwing. 

The  amount  of  lactic  acid  present  in  buttermilk  has 
been  carefully  studied.  Robertson,  a  chemist,  found  it 
to  be: — 

Minimum    0.09  per  cent. 

Maximum     0.45  per  cent. 

De  Jager  believes  that  good  buttermilk  does  not  con- 
tain more  than  0.5  per  cent,  of  free  lactic  acid.35  These 
are,  however,  not  absolute  and  positive  data,  but  really 
individual  hypotheses. 


35  Nederlandsch  Tydschrift  voor  Geneeskundigebladen,   1899,  i, 
S.  945. 


BUTTERMILK-FEEDING.  117 

Contrary  to  the  ideas  of  Munk,  Uflelmann,  and  Ewald 
(who  fear  the  use  of  food  containing  lactic  acid),  de  Mat- 
tos  has  found  that  chronic  enteritis  and  gastric  complaints 
soon  improve  when  an  exclusive  buttermilk  feeding  is 
resorted  to.  Hayem  and  Lesage  regard  lactic  acid  as  en- 
tirely innocuous  for  nurslings.  According  to  the  above- 
named  investigators,  lactic  acid  is  not  toxic  for  infants. 
They  gave  experimentally  15  to  20  grains  in  divided 
doses,  mixed  with  sugar,  without  seeing  any  detrimental 
results.  Jaworski36  found  no  trace  of  lactic  acid  in  an 
infant's  stomach  one  hour  after  administering  it. 

Biel  maintains  that  lactic  acid  improves  digestion, 
while  Duclaux37  states  that  lactic  acid  is  a  valuable  as- 
tringent. Heubner38  found  lactic  acid  in  the  stomach 
of  two  healthy  infants  (to  the  extent  of  0.16  to  0.2  per 
cent.).  Marfan  (quoting  Zotow)  maintains  that,  when 
lactic  acid  is  found  in  the  stomach  of  infants,  it  is  always 
a  pathological  factor. 

Buttermilk  in  its  crude  (raw)  state  is  certainly  an- 
tagonistic to  other  micro-organisms.  This  is  due  to  the 
presence  of  lactic-acid  bacilli.  Raw  cows'  milk  possesses 
bactericidal  properties,  but  buttermilk  is  much  more  bac- 
tericidal. The  latter,  sterilized  with  the  aid  of  steam, 
showed  virulent  typhoid  bacilli  nine  days  after  being  in- 
oculated with  the  same.  In  non-sterilized  buttermilk 
{raw  state)  virulent  typhoid  bacilli  lost  their  virulence 
after  two  days,  and  when  put  into  the  brooding  oven  lost 
their  virulence  after  twenty-four  hours.  The  bacillus 
lacticus  of  Pasteur  and  Hueppe  seems  to  be  identical  with 
the  bacillus  lactis  aerogenes  of  Escherich,39  which  is  found 
in  the  upper  part  of  the  small  intestine. 

Jaworski  found  that  pepsin  is  more  readily  secreted 
when  lactic  acid  is  given  internally.     De  Mattos  states 

36  Deutsches  Archiv  f iir  klinische  Medicin,  Bd.  xxxvii,  i. 

37  "Maladies  de  PEnfance,"  tome  ii,  p.  606. 

38  "Jalirbuch  fur  Kinderheilkunde,"  1891. 

89  "Die  Darmbacterien  des  Sauglings,"  Stuttgart,  1SS6. 


118  INFANT-FEEDING. 

that  he  has  never  met  with  a  case  of  Barlow's  disease 
among  infants  fed  with  buttermilk. 

Disagreeable  symptoms  are  frequently  encountered 
for  the  first  few  weeks  while  giving  buttermilk.  Such 
are  frequent  vomiting  and  diarrhoea.  These  are  not 
contra-indications  for  feeding,  and,  notwithstanding  the 
presence  of  the  above-named  symptoms,  the  feeding  should 
be  continued.  If,  however,  the  symptoms  are  very  severe, 
then  the  administration  of  astringents — such  as  bismuth, 
argent  nitrate,  tannalbin,  or  ichthalbin — may  be  required 
for  temporary  relief. 

An  important  point  is  that  in  this  form  of  infant- 
feeding  the  large,  thick,  cheesy  curds  so  commonly  met 
with  in  dyspepsia  and  diarrhoeas  in  feeding  with  cows' 
milk  are  never  seen.  Children  thus  fed  seem  to  with- 
stand the  infectious  diseases  very  well.  A  point  worth 
noting  is  that  when  a  child  is  more  accustomed  to  butter- 
milk feeding  the  change  to  sweet  milk  will  cause  diar- 
rhoea. 

When  we  find  that  the  weight  is  not  increased  and 
we  desire  to  change  to  sweet  milk,  the  latter  should  be 
gradually  adoled  to  the  buttermilk  instead  of  making  a 
distinct  change  suddenly. 

Quality  of  the  Buttermilk. — This  is  the  most  impor- 
tant part  of  our  subject.  In  securing  our  food  we  must 
be  sure  that  w&  are  dealing  with  honest  dairymen  whose 
sole  object  is  to  deliver  what  is  demanded  for  weak  in- 
fants. Stale  combinations  made  by  the  use  of  left-over 
centrifuged  milk  or  skim-milk  or  spoiled  milk  which 
cannot  be  used  otherwise  should  be  inquired  into  and 
rejected. 

Good  buttermilk  can  be  made  from  either  whole  milk 
or  from  cream.  In  Holland  buttermilk  is  made  by  pas- 
teurizing cream  in  Timpe's  apparatus  and  then  inoculat- 
ing and  buttering  the  same  with  a  pure  culture  of  lactic- 
acid  bacillus.  In  order  that  raw  milk  will  yield  butter- 
milk a  certain  percentage  of  acidity  must  be  present. 


BUTTERMILK-FEEDING. 


119 


The  usual  precautions  in  milking  (so-called  modern 
stable  hygiene)  must  be  observed  in  securing  milk  to  be 
used  in  making  buttermilk.  The  milk  should  be  received 
in  sterile  vessels  and  rapidly  cooled,  and  should  then  be 
kept  in  cool  cellars  or  ice-coolers  having  a  low  tempera- 
ture (no  higher  than  15°  or  20°  C.)  for  eighteen  to 
twenty-four  hours.  It  is  necessary  to  stir  the  milk  occa- 
sionally. Rapidity  of  souring  can  be  assisted  by  adding 
sour  milk  or  by  inoculating  with  a  pure  culture  of  lactic- 
acid  bacilli.  ]STo  definite  rule  can  be  laid  down  as  to  when 
buttering  takes  place;  empiric  methods  must  decide  this 
matter.  This  is  due  to  the  size  of  the  vessel  used  and 
the  influence  of  seasonal  changes,  and  also  the  amount 
of  churning  it  had  received.  Cows'  milk  which  contains 
colostrum  or  which  is  bitter  is  not  adapted  for  buttering. 

Butter  should  form  in  small,  pin-head-sized  particles 
in  thirty  to  forty-five  minutes.  It  is  regarded  as  a  mis- 
take to  have  large  particles  of  the  size  of  a  pea  or  larger, 
and  dairymen  look  upon  such  buttermilk  with  suspicion. 
Buttermilk  in  general  contains  about  0.3  to  0.4  per  cent, 
of  fat. 

Escherich  states  that  the  fermentation  of  milk  is  due 
to  the  splitting  up  of  the  milk-sugar  whereby  lactic  acid, 
0,  and  C02  are  formed  in  the  intestine. 

The  following  table  is  instructive  in  showing  the  per- 
centage of  acidity  present  and  also  the  difference  in  fat: — 


Specific 
Gravity. 

Solids, 
Percentage. 

Fat. 

Acidity  According 
to  Soxhlet-Hf.nkel. 

Sour  milk  before 
buttering 

1.029 

11.40 

2.8 

18.1 

Buttermilk 

1.029 

9.60 

0.5 

16.1 

There  is,  therefore,  a  difference  of  2  per  cent,  in  the 
amount  of  acidity  present  in  favor  of  buttermilk. 


120  INFANT-FEEDING. 

An  important  point  is  to  overcome  the  lum.ps  usually 
found  as  coarse  coagula  in  buttermillc.  De  Mattos  advises 
adding  flour — either  rice,  wheat,  or  lentil — or  even  some  pro- 
prietary infant-foods,  according  to  the  requirements  of  the 
infant. 

This  is  merely  given  to  hold  the  flocculi  in  finer  form 
and  to  prevent  their  coagulation  into  lumps.  Dyspeptic 
children  with  subnormal  digestive  powers  should  receive 
a  minimal  quantity;  thus,  an  even  tablespoonful,  amount- 
ing to  about  10  grammes,  will  suffice. 

Addition  of  Sugar.  —  The  quantity  of  sugar  to  be 
added  must  be  reckoned  empirically;  thus,  3  tablespoon- 
fuls,  about  90  grammes,  are  required  to  each  liter  of 
buttermilk.    Rarely  do  we  need  more  than  100  grammes. 

Cane-sugar  or  beet-sugar  serves  best  for  sweetening. 
Sugar  cannot  be  found  in  the  urine  nor  in  the  faeces  of 
infants  fed  on  buttermilk  to  which  sugar  was  added. 

The  results  which  might  be  expected  from  using  cane- 
sugar — such  as  diarrhoea,  fermentation,  sour  eructations 
— are  totally  absent  in  using  buttermilk  feeding. 

Stools.  —  The  average  buttermilk-fed  infant  has  no 
more  than  one  or  two  stools  daily.  They  are  more  or 
less  solid  in  consistency  and  have  an  alkaline  reaction. 
It  would  be  incorrect  to  state  that  all  children  fed  with 
buttermilk  must  have  yellow  stools.  We  know  that  even 
UfTelmann,  in  his  studies  of  infant-stools,  states  that 
breast-fed  infants  show  great  variations  from  apparent 
normal  stools  and  still  thrive.  We  also  know  that  bottle- 
fed  infants  reared  on  cows'  milk  have  no  definite  hind 
of  stool  which  we  could  call  a  standard  stool.  Still,  the 
buttermilk-fed  infant  never  has  the  coarse  casein  particles 
in  the  faeces  that  we  see  very  frequently  in  the  stools  of 
infants  fed  on  cows'  milk. 

The  bacteriological  examination  of  the  faeces  made 
by  inoculating  gelatin  plates  with  diluted  faeces  showed: — 

1.  Liquefying  colonies  rendered  Loeffler's  nutrient 
gelatin  strongly  alkaline.     Inoculated  into  bouillon,  the 


BUTTERMILK-FEEDING.  121 

latter  remained  clear,  forming  a  skim  on  the  surface. 
Milk  was  not  coagulated  by  these  micro-organisms.  They 
formed  spores,  generated  H2S,  and  can  therefore  be  iden- 
tified as  the  bacillus  butyricus  of  Hueppe. 

2.  ISTon-liquefying  colonies  were  inoculated  into  milk- 
sugar  bouillon  and  left  in  the  brooding  oven  eight  hours 
at  37  °C.  All  tubes  so  treated  were  turbid  on  standing 
over  night;  this  fact  excludes  the  possibility  of  its  being 
the  bacterium  coli. 

Other  properties  were  found,  such  as:  fermentation 
in  milk-sugar  bouillon,  no  skim  forming  on  the  bouillon; 
indol  does  not  form  in  peptone  solution  (bacterium  coli 
would  form  indol);  milk  turns  sour  but  slowly;  no  ]SFH3 
formation. 

From  a  study  of  the  above  properties  we  conclude: — ■ 

1.  Bacterium  coli  commune  must  be  excluded. 

2.  Bacterium  coli  lactici,  Hueppe  (resp.  bacterium 
lactis  aerogenes,  Escherich),  must  be  identified. 

The  lactic-acid  bacillus,  found  in  boiled  as  well  as 
raw  buttermilk,  loses  its  potency  in  the  intestinal  canal 
in  the  presence  of  the  bacillus  butyricus,  Hueppe.  The 
latter  germ  grows  in  overwhelming  numbers  and  renders 
the  intestinal  contents  rapidly  alkaline. 

An  interesting  point  is  that,  if  the  buttermilk  were 
originally  very  sour,  the  faeces  will  be  very  alkaline,  show- 
ing how  weak  the  bacterium  acidi  lactici  is. 

Feeding. — The  writer  has  seen  excellent  results  from 
buttermilk  feeding  in  atrophic  and  marasmic  children. 
As  an  article  of  diet  during  convalescence  after  pneu- 
monia and  typhoid  fever  the  results  were  encouraging. 

Quantity  to  be  Fed. — Buttermilk  as  above  prepared 
should  be  fed  exactly  as  would  other  milk.  Four  ounces, 
increased  to  5  or  6  ounces,  can  be  fed  every  3  hours,  or 
the  interval  may  be  prolonged  to  3  1/2  or  4  hours.  It 
will  be  necessary  to  coax  the  child  in  beginning  with  this 
new  form  of  feeding,  owing  to  the  difference  in  the  taste 
of  fresh  milk  and  buttermilk. 


CHAPTER  XVIII. 

Detection  and  Addition  of  Preservatives  to  Milk. 

The  preservatives  most  frequently  employed  are: 
borax  and  boric  acid,  formaldehyde,  salicylic  acid,  and 
potassium  clir ornate. 

Formaldehyde40  is  the  most  effective,  and,  when  the 
same  becomes  better  known,  it  will  supersede  all  other 
preservatives.  The  above  chemicals  are  sold  to  farmers 
and  dairymen  as  "milk-preservatives."  The  table  on  the 
following  page  will  show  the  efficiency  of  the  various 
milk-preservers,  and  is  taken  from  T.  H.  Pearmain  and 
C.  G.  Moor,  on  "Milk  and  Milk-products." 

Formaldehyde  is  usually  added  to  milk  in  the  form 
of  a  40-per-cent.  solution,  commonly  called  formalin;  2 
or  3  drops  added  to  a  pint  of  milk  will  keep  it  fresh  for 
three  or  four  days,  and  the  addition  of  0.05  per  cent, 
will  preserve  milk  for  months.  In  the  trade  a  much  more 
dilute  solution  is  generally  employed,  namely:  1  part  of 
formaldehyde  to  80  parts  of  water.  Rideal  states  that  a 
quarter  of  a  pint  of  such  a  solution  will  keep  seventeen 
or  eighteen  gallons  of  milk  fresh  for  at  least  three  days, 
and  will  not  impart  any  smell  or  taste  to  the  same.  On 
tasting  milk  containing  formaldehyde  a  peculiar  sensa- 
tion is  noticed  at  the  back  of  the  throat,  and  when  strong 
hydrochloric  acid  is  added  to  it  (Werner  Schmidt  process) 
the  casein  turns  yellow  and  is  less  soluble  than  that  of 
pure  milk.     Hehner's  test  is  the  most  reliable.     When 


40  The- New  York  Medical  Record,  as  recently  as  July  21,  1900, 
contains  the  following:  — 

"Many  milk-dealers  in  New  Jersey  have  been  arrested  on  the 
complaint  of  the  State  dairy  commissioner  for  adulterating  milk, 
the  special  adulterant  being  formaldehyde,  added  as  a  preservative." 

(122) 


DETECTION  AND  ADDITION  OF  PRESERVATIVES. 


123 


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124  INFANT-FEEDING. 

milk,  formalin,  and  sulphuric  acid  are  mixed  together  a 
blue  coloration  is  formed.  According  to  Richmond  and 
Bosely,  it  is  best  to  dilute  the  milk  with  equal  quantities 
of  water  and  add  sulphuric  acid,  about  90-  to  94-per-cent. 
strength.  When  formalin  is  absent,  the  milk  gives  a 
slight-greenish  tinge  at  the  junction  of  the  two  liquids, 
while  a  violet  ring  is  formed  when  formaldehyde  is  pres- 
ent. This  color  remains  permanent  for  several  days.  In 
the  absence  of  formalin,  a  brownish-red  color  is  developed 
after  some  hours,  not  at  the  junction  of  the  two  liquids, 
but  lower  down  in  the  acid.  This  cannot  be  mistaken 
by  anyone  who  has  had  any  experience  with  the  test  for 
the  formaldehyde  reaction.  It  is  stated  that  1  'part  of 
formalin  can  he  easily  detected  by  means  of  this  test  in 
200,000  parts  of  milk,  but  the  blue  coloration  is  not  ob- 
tained with  milk  containing  over  0.5  per  cent. 

Another  very  sensitive  test  for  the  detection  of  for- 
malin in  cows'  milk  is  the  following:  If  to  the  distillate 
from  a  sample  of  milk  1  drop  of  a  dilute  aqueous  solution 
of  phenol  is  added  and  the  mixture  poured  upon  strong 
sulphuric  acid  contained  in  a  test-tube,  a  bright-crimson 
color  appears  in  the  zone  of  contact.  This  color  is  still 
readily  seen  with  1  part  of  formaldehyde  in  200,000  of 
water.  If  there  is  more  than  1  part  in  100,000  there 
is  seen  above  the  red  ring  a  white,  milky  zone,  while  in 
stronger  solutions  a  copious  white  or  slightly  pink,  curdy 
precipitate  is  obtained.  This  reaction  has  an  advantage 
over  the  one  previously  referred  to,  as  it  is  obtained  with 
formaldehyde  solutions  of  all  strengths,  while  the  blue 
color  of  milk  is  not  obtained  with  milk  containing  much 
formaldehyde. 

Salicylic  acid  is  not  very  much  in  vogue  as  a  milk- 
preservative.  It  can  easily  be  detected  by  Pellet's  method : 
200  cubic  centimetres  of  the  milk  are  diluted  with  an 
equal  measure  of  water,  heated  to  60°  O.  and  treated  with 
1  cubic  centimetre  of  acetic  acid  and  an  excess  of  mer- 
curic nitrate  free  from  mercurous  salt.    The  salicylic  acid 


DETECTION  AND  ADDITION  OF  PRESERVATIVES.  125 

is  extracted  from  the  filtered  solution  by  agitation  in  ether 
and  recognized  by  evaporating  a  little  of  the  ethereal 
solution  to  dryness  and  testing  the  residue  with  ferric 
chloride,  which  gives  a  violet  color  with  salicylic  acid. 

Pearmain  and  Moor,  in  describing  the  bacteriology  of 
milk,  say  that  it  usually  contains  a  large  number  of  bac- 
teria derived  from  the  external  surroundings  of  the  cow. 
Where  these  are  unclean,  the  number  may  reach  three  or 
more  millions  per  cubic  centimetre.  These  can,  "for  ex- 
perimental purposes,"  be  completely  separated  by  filtra- 
tion through  Pasteur  tubes,  the  tubes  being  cleaned  at 
short  intervals.  A  thin,  watery  serum  constitutes  the 
filtrate,  the  whole  of  the  fat  being  arrested  with  the 
organisms,  so  that  milk  cannot  therefore  be  freed  from 
organisms  for  practical  purposes  by  any  known  system 
of  filtration.  Milk  can  be  curdled  by  ferments  even  in 
the  absence  of  an  acid  reaction.  The  most  notable  fer- 
ment is  rennet,  obtained  from  the  stomach  of  a  calf. 
ITueppe  first  pointed  out  that  such  ferments  are  conveyed 
by  many  different  bacteria  which  precipitate  the  casein 
in  the  presence  of  a  weakly  acid,  amphoteric,  or  even 
neutral  solution.  The  numerous  tyrothrix  bacilli  isolated 
by  Duclaux,  the  bacillus  pyocyaneus,  yellow  sarcina,  and 
particularly  the  organisms  described  by  Fliigge,41  char- 
acterized by  their  capacity  to  peptonize  milk,  belong  to 
this  class.  Colin42  produced  the  precipitation  even  by 
means  of  bacteria,  whose  vegetative  capacity  had  been 
completely  abolished  with  chloroform,  thus  showing  that 
the  fermentative  action  was  due  to  a  substance  independ- 
ent of  the  metabolic  products  of  the  organism.  These 
substances  have  been  isolated  by  Cohn  and  others.  They 
are  destroyed  in  most  cases  at  from  65°  to  75°  C.  Some 
ferments,  however,  as,  for  example,  that  described  by 
Gorini  in  association  with  the  bacillus  prodigiosus,  resist 


41  Zeitschrift  fur  Hygiene,  xvii,  page  272. 

42  Centralblatt  fiir  Bacteriologie,  ix,  page  653. 


126  INFANT-FEEDING. 

as  much  as  an  hour's  exposure  to  70°  or  80°  C,  and 
require  at  least  half  an  hour's  exposure  to  100°  C.  (or 
212°  F.)  for  their  destruction. 

It  is  practically  inevitable  that  milk,  as  delivered 
from  the  cow,  should  contain  a  number,  and  usually  a 
very  large  number,  of  bacteria.  The  extent  of  their 
presence  is,  however,  affected  by  many  circumstances,  of 
which  some  are  also  indications  of  unwholesomeness  or 
danger.  Many  of  the  organisms  which  are  capable  of 
causing  disease  do  so  by  producing  toxic  •  decomposition- 
products  from  the  milk.  Their  vegetative  capacity  in- 
creases greatly  with  rise  of  temperature,  and  it  is  there- 
fore an  essential  condition  of  sanitary  milk-production, 
and  especially  of  a  milk  designated  as  suitable  for  children, 
that  it  should  be  kept  at  a  low  temperature  during  the 
whole  of  the  interval  between  being  drawn  and  being  con- 
sumed. 

Yellow  milk  is  said  to  be  colored  by  the  bacillus  syn- 
xanthus  of  Schroter,  the  color  being  removed  by  acids  and 
restored  by  alkalies. 

Salty  milk  is  stated  to  occur  only  in  connection  with 
inflammation  of  the  udder.  It  is  to  be  detected  not  only 
by  its  taste  and  its  high  percentage  of  ash,  but  by  its  low 
percentage  of  milk-sugar.  Its  specific  gravity  is  1.027 
to  1.029.  According  to  Klenze,  2.4  per  cent,  of  small 
deposits  of  calcium  carbonate  in  the  milk-glands  may  give 
rise  to  sandy  milk.  Curious  results  have  been  noted  by 
Scheurlen43  in  experimenting  with  bacteria  in  milk.  He 
found  that  milk  can  be  freed  from  bacteria  by  the  opera- 
tion of  a  centrifugal  machine.  He  also  noted  that,  of  the 
large  majority  of  bacteria  contained  in  milk,  three-fourths 
went  into  the  cream  on  being  centrifugalized,  and  the 
rest  stayed  in  the  separated  milk,  and  the  same  result  was 
obtained  by  merely  leaving  the  milk  stand.  These  results 
held  good  not  only  for  the  ordinary  milk  bacteria,  but  also 


"Arbeiten  a.  d.  k.  Ges.  Amt.3  vii3  1891. 


THE   BREED   OF   A   COW.  127 

for  anthrax,  typhoid,  and  cholera.  The  tubercle  bacillus 
only  remained  to  a  small  extent  in  either  the  milk  or  the 
cream,  and  the  large  majority  was  ejected  under  the  cen- 
trifugal influence.  The  biological  commission  on  milk- 
supply  held  under  the  auspices  of  the  British  Medical 
Journal  for  1895,  reported  the  following:  1.  That  all 
milking  be  carried  on  in  the  open  air,  the  animal  and 
operators  standing  on  a  material  which  is  capable  of  being 
thoroughly  washed,  such  as  a  floor  of  concrete  or  cement. 
Such  a  floor  could  be  easily  laid  down  in  any  convenient 
place  which  can  be  found.  The  site  chosen  should  be  re- 
moved from  inhabited  parts  as  far  as  possible,  and  should 
be  provided  with  a  plentiful  water-supply.  Only  in  this 
way  does  it  seem  possible  to  avoid  the  initial  contamina- 
tion with  the  colon  bacillus.  2.  That  greater  care  should 
be  expended  on  the  personal  cleanliness  of  the  cows;  the 
only  too  familiar  picture  of  the  animal's  hindquarters, 
flanks,  and  side  being  thickly  plastered  with  mud  and 
faeces  is  one  that  should  occur  no  longer.  It  would  not; 
be  difficult  to  carry  out  this  change.  Indeed,  in  the  better 
managed  of  our  large  dairy  companies'  farms  such  a  con- 
dition no  longer  prevails,  but  in  the  smaller  farms  it  is 
but  too  frequently  met  with.  3.  That  the  hands  of  the 
milker  be  thoroughly  washed  before  the  operation  of 
milking  is  commenced,  and  that  after  once  being  washed 
they  be  not  again  employed  in  handling  the  cow,  other- 
wise than  in  the  necessary  operation  of  milking.  Any 
such  handling  should  be  succeeded  by  another  washing  in 
fresh  water  before  again  commencing  to  milk.  4.  That 
all  milk-venders'  shops  should  be  kept  far  cleaner  than 
is  often  the  case  at  present;  that  all  milk-retailing  shops 
should  be  compelled  to  provide  proper  storage  accommo- 
dation, and  that  the  counters,  etc.,  should  be  tiled. 

The  Breed  of  a  Cow. 

Some  breeds  yield  quantity,  others  quality.    Tlolsteins 
produce  the  most  milk;   Alderneys  and  Jerseys  yield  the 


128  INFANT-FEEDING. 

most  fat ;  shorthorns  give  the  most  casein  and  sugar.  The 
average  capacity  of  a  cows'  udder  is  about  5  pints,  and 
the  annual  yield  of  milk  is  about  600  gallons. 

Time  and  Stage  of  Milking. 

Cows  are  usually  milked  twice  a  day,  the  morning 
milk  usually  being  larger  in  quantity  and  poorer  in  qual- 
ity. The  milk  which  is  first  drawn  is  known  as  the  fore- 
milk, and  contains  very  much  less  fat  than  that  last  drawn, 
known  as  the  strippings.  This  is  due  to  a  partial  cream- 
ing taking  place  in  the  udders.  Dishonest  dealers  have 
often  taken  advantage  of  this  fact  in  adulteration  cases  to 
have  the  cows  partially  milked  in  the  presence  of  ignorant 
witnesses,  the  resulting  milk  consisting  largely  of  the  fore- 
milk. 

Age  of  Cows. 

Young  cows  give  less  milk,  while  cows  from  four  to 
seven  years  old  give  the  richest  milk,  and  less  milk  is 
given  with  the  first  calf.  They  give  the  largest  yield,  ac- 
cording to  Fleishmann,  after  the  fifth  until  the  seventh 
calf;  after  the  fourteenth  calf  they  yield,  as  a  rule,  no 
more  milk.  The  poorest  milk  is  yielded  during  the  spring 
and  early  summer;  the  richest  during  the  autumn  and 
early  winter.  If  cows  are  worried  or  driven  about,  the 
quality  and  quantity  of  the  milk  are  reduced.  If  they 
are  kept  warm  and  well  fed,  both  quantity  and  quality 
are  naturally  increased. 

Effect  of  Alkalies  on  Milk. 

By  running  milk  through  a  centrifugal  machine  a 
product  known  as  "separator  slime"  is  produced,  which  is 
analogous  to  mucin.  A  decided  difference  in  viscosity  is 
noticed  between  milk  before  and  after  running  it  through 
a  centrifugal  machine.  This  "separator  slime"  swells  up 
and  forms  a  viscid  jelly  with  lime-water  or  alkalies.  Milk 
to  which  alkali  is  added  is  decidedly  more  viscous  than 


ALBUMINOIDS    IN    COWS*    MILK.  129 

milk  that  is  slightly  acid,  and  is  so  undoubtedly  because 
of  the  action  of  the  alkali  on  the  mucin  of  the  milk. 

CuKDLING    OF    MlLK    AND    DlLUENTS. 

Milk  of  all  animals  may  be  separated  into  two  classes. 
Those  that  form  a  soft  curd  with  rennet  and  those  that 
form  a  hard  curd  with  rennet.  Woman's 'milk  is  in  the 
first  class  and  cows'  milk  in  the  second. 

The  conditions  favorable  for  the  formation  of  hard 
curds  of  cows'  milk  are  body-heat  and  the  presence  of 
rennet  and  lactic  or  other  acid. 

The  rennet  forms  a  clot  of  the  milk,  the  heat  causes 
the  lactic  bacteria  to  grow  in  the  curd,  and  the  acid  causes 
the  curd  to  shrink  and  become  leathery.  Adding  alkalies 
to  the  milk  neutralizes  the  acid,  but  the  bacteria  will  keep 
making  more  lactic  acid  as  long  as  any  sugar  is  present. 

Diluting  milk  with  water  does  not  prevent  tough 
curds  forming,  but  diluting  with  gruels  does  prevent  the 
contraction  of  the  curds.  This  has  been  proved  beyond 
dispute,  both  experimentally  and  clinically. 

Albuminoids  in  Cows'  Milk. 

That  there  are  differences  in  the  amounts  of  the  albu- 
minoids occurring  in  human  milk  is  proved  by  the  fact 
that,  while  Professor  Leeds  found  a  variation  of  0.85  to 
4.86,  Professor  Meiggs  asserts  that  there  was  but  1  per 
cent. 

Konig,  an  earlier  analyst,  makes  the  variation  from 
0.85  to  4.86.  Some  of  these  results  give  as  high  a  per- 
centage of  albuminoids  in  woman's  milk  as  we  find  in 
cows'  milk,  and  I  have  no  doubt  in  my  own  mind  that 
the  time  and  habit  of  extracting  the  milk  has  a  deal  to 
do  with  the  amount  of  occurring  albuminoids.  In  other 
words,  when  milk  is  extracted  every  two  hours  or  less,  it 
cannot  contain  as  much  of  the  cell-material  as  milk  from 
the  same  source  extracted  at  intervals  of  twelve  hours. 
This  latter  is  riper  and  it  is  the  non-uniformity  of  the 


130  INFANT-FEEDING. 

tissue  which  causes  all  the  difference  in  the  different  oc- 
curring albuminoids.  We  know  that  during  the  incuba- 
tion of  eggs  casein  is  developed  from  egg-albumin.  This 
illustrates  the  ripening  of  albumin.  Furthermore,  take 
an  egg  just  laid  by  the  hen,  and  boil  it,  and  you  will  find 
immature  albumin  in  it;  that  is,  after  boiling,  instead  of 
being  thick  and  firm,  like  an  older  egg,  much  of  it  is 
milky.  If  boiled  a  few  hours  later,  all  the  albumin  will 
coagulate  perfectly,  because  it  has  had  time  to  ripen. 
There  is  no  doubt  that  the  albuminoids  in  milk  from 
healthy  animals  are  all  cell-transformations,  not  an  exu- 
date, as  are  undoubtedly  the  fats  and  salts,  because  these 
latter  we  can  influence  by  the  food  very  plainly,  but  in 
health  the  albuminoids  are  constant  without  regard  to 
food,  while  during  menstruation,  pregnancy,  and  other 
conditions,  notably  febrile  disturbances,  we  find  the  fats 
and  salts  not  materially  affected,  but  the  albuminoids  de- 
creased, increased,  or  totally  changed,  as  in  the  case  of 
colostrum.  The  casein,  besides  being  riper  in  cows'  milk, 
by  reason  of  its  stronger  growth,  is  intended  by  Nature 
to  coagulate  into  a  hard  mass,  because  it  is  the  product 
of  a  cud-chewer  for  the  nourishment  of  a  cud-chewer, 
and  the  reason  why  it  does  not  always  coagulate  in  the 
infant's  stomach  as  it  does  in  that  of  the  calf  is  that  the 
latter  animal's  stomach  secretes  a  principle  called  chy- 
mosin;  this  is  the  principle  that  curdles  cows'  milk,  and 
it  operates  either  in  an  acid  or  an  alkaline  medium.  Pep- 
sin will  not  coagulate  milk,  and  hence  the  hard  coagulum 
of  cows'  milk  that  sometimes  forms  in  the  infant's  stom- 
ach is  due  to  acidity  of  that  organ,  and  this  acidity  is  not 
always  the  fault  of  the  stomach,  but  of  the  milk  itself. 
The  variations  in  the  chemistry  of  the  albuminoids  found 
in  cows'  milk  would  not  be  surprising  to  anyone  if  he 
would  examine  into  the  condition  of  some  of  its  mam- 
mary sources.  Thus  it  will  often  be  found,  on  dissecting 
a  cow's  udder,  which  I  always  do  when  making  an  au- 
topsy on  a  cow,  that  there  are  old  cicatrices,  one  or  more 


ALBUMINOIDS    IN"    COWS'    MILK.  131 

quarters  of  the  udder  intensely  inflamed,  sometimes  a 
mammiferous  duct  clogged  with  a  calculus  or  a  clot  of 
fibrin.  Besides  these  pathological  conditions,  the  mam- 
mary gland  is  subject  to  benign  and  malign  infiltrations, 
bacillary  tubercular  deposits,  and  eruptive  diseases  of  the 
skin  involving  the  gland  and  ducts.  Therefore,  that 
fibrin,  serum,  and  albumin,  in  various  forms,  are  found 
in  the  cows'  milk  is  not  surprising,  and  it  can  safely  be 
assumed  that  any  variation  in  the  albuminoids  from  the 
normal  casein  can  be  ascribed  to  sickness  on  the  part  of 
the  animal. 

"We  next  come  to  the  salts  contained  in  milk,  and  it 
is  remarkable  how  few  analyses  have  been  made  to  deter- 
mine the  salts  or  minerals  that  are  contained  in  this  fluid. 
Heidlen's  analysis,  copied  everywhere,  seems  to  be  the 
only  exhaustive  one  of  the  salines  in  cows'  milk  made 
during  the  past  century.  It  seems  to  me  in  this  case, 
too,  that  it  is  time  for  the  chemist  to  teach  us  something 
more.  There  probably  never  was  a  time,  in  our  era,  at 
least,  when  milk  was  attracting  so  much  attention  as  now, 
and  still  all  our  chemists  are  content  with  the  total  solids, 
fats,  albuminoids  and  sugar — just  what  the  butter-makers 
and  cheese-makers  want  to  know.  From  this  much-quoted 
analysis  of  cows'-milk  salts  we  learn  that  milk  contains  in 
various  proportions  the  phosphates  of  lime,  magnesia,  and 
iron;  the  chlorides  of  potassium,  sodium,  and  iron;  and 
free  soda.  Robin  gets  from  human  milk,  in  addition  to 
the  foregoing,  carbonate  of  lime  and  soda,  phosphate  of 
soda,  sulphate  of  soda,  and  potash.  We  have  no  means 
of  knowing  how  constant  is  the  occurrence  of  any  of  these 
salts  in  milk  or  under  what  conditions  they  are  modified; 
we  do  know,  however,  from  the  experiments  of  Fehling, 
that  many  of  the  drugs  administered  to  the  milking  fe- 
male are  excreted  in  the  milk.  Therefore,  we  can  safely 
assume  that  the  saline  constituents  occurring  in.  milk  are 
influenced  both  by  the  health  and  food  of  the  animal. 
That  the  phosphates  are  craved  for  oy  the  milking  cow  is 


132  INFANT-FEEDING. 

evidenced  by  the  habit  of  chewing  old  bones  and  the  like, 
and  that  there  is  a  lack  of  this  element  of  food  is  not  to 
he  wondered  at  when  we  see  herds  of  milking  cows  pas- 
tured on  old,  worn-out  lands;  the  practical  farmer  knows 
that  exhausted  pasture-lands  need,  more  than  anything 
else  for  their  rejuvenescence,  the  phosphates,  and  we 
know  that  in  our  nutrition  we  need  them  also.  The  land 
on  which  a  cow  is  pastured  will  indicate  pretty  fairly 
what  we  may  expect  to  find  in  her  milk  as  salts.  We 
have  all  noticed  the  excessive  growth  of  sorrel  on  ex- 
hausted land.  Can  it  then  be  a  subject  of  wonder  that 
some  kind  of  a  vegetable  acid  should  be  found  in  the  milk 
of  animals  that  are  obliged  to  include  this  variety  of  food 
in  their  summer-rations  and  sour  ensilage  or  spoiled  brew- 
ery grains  in  their  winter-feed?  Theodore  Hankel's  dis- 
covery of  citric  acid  in  cows'  milk  to  the  amount  of  0.9 
and  1.1  grammes  per  litre  is  just  what  might  be  expected. 

Sugar,  I  think,  in  milk  has  always  been  overestimated 
as  to  its  nutritive  value,  because  we  know  that  carnivo- 
rous animals  do  not  secrete  sugar  to  any  appreciable  ex- 
tent, according  to  chemists.  When  we  see  a  small  slut 
nursing  seven  or  eight  puppies  and  keeping  them  all  fat, 
and  in  a  thriving  condition,  we  can  easily  imagine  that 
sugar  is  not  a  necessary  element  of  food,  for  the  canines 
excrete  no  sugar  in  their  milk.  We  see  that  the  gross  re- 
sult of  condensed-milk  feeding  with  an  excess  of  sugar  is 
harmful.  Brush  maintains  that  pure  cane-sugar  is  the 
ideal  addition  to  cows'  milk. 

Prof.  L.  B.  Arnold,  an  authority  on  dairy  matters, 
says  that  when  milk  will  not  properly  nourish  an  infant 
it  is  not  the  cows'  milk  that  is  at  fault,  but  that  it  is 
either  a  pathological  condition  of  the  cow  or  improper 
food  or  care,  or  the  conditions  through  which  the  milk 
has  passed  on  its  way  from  the  cow  to  the  infant. 

The  average  temperature  of  a  cow  is  102  1/2°  F. 
(Brush).  "This  is  certainly  a  peculiarity  of  the  cow.  An- 
other peculiarity  is  the  constant  employment  of  her  gen- 


ALBUMINOIDS    IN    COWS'    MILK.  133 

erative  functions :  she  is  always  milking  or  pregnant,  and 
both  the  uterus  and  the  mammary  glands  are  employed 
almost  constantly  at  the  same  time.  Her  nervous  system 
is  more  subject  to  severe  shocks,  and  she  is  a  delicate 
creature.  As  regards  the  average  income  from  a  cow,  it 
is  about  $20.00  a  year  to  the  producer.  This  is  about 
7  cents  a  day,  from  which  the  dairyman  has  to  buy  food 
and  pay  for  labor.  In  order  to  make  a  profit  the  dairy- 
man must  utilize  every  drop  of  milk,  whether  the  animal 
giving  it  be  sick  or  well.  It  is,  therefore,  very  common 
to  find  that  all  the  cheap  foods,  such  as  brewery  grains, 
distillery  slops,  and  the  refuse  from  starch-factories  enter 
largely  into  the  food  from  which  our  babies'  supply  of 
milk  is  produced.  Brush  maintains  that  personal  inspec- 
tions of  small  dairies  near  New  York  City  showed  the  sole 
article  of  diet  to  be  swill.  One  of  the  means  employed 
for  removing  the  stable  odors  of  milk  is  adding  nitrate 
of  potash,  commonly  known  as  "saltpeter."  With  this 
drug  a  substance  resembling  nitroglycerin  is  formed.  It 
is  strange  that  the  toxic  effects  of  nitroglycerin  are  sim- 
ilar to  those  of  tyrotoxicon. 

Brush  believes  that  the  ideal  dairy  for  supplying  in- 
fant-food should  be  composed  entirely  of  spayed  cows, 
and  thus  one  constant  source  of  nervous  function  of  dis- 
turbance would  be  eliminated.  He  believes  that  these 
animals  are  much  more  quiet  in  disposition,  they  give  a 
more  constant  and  uniform  supply  of  milk,  and  seem  to 
enjoy  a  more  even  degree  of  health  than  the  cow  who  is 
occasionally  bulling  and  becoming  pregnant  when  giving 
milk.  The  author  has  certainly  had  very  good  results 
with  Brush's  milk,  and,  although  it  is  somewhat  expensive, 
he  has  found  it  well  adapted  for  the  home-modification  of 
infants'  food. 


CHAPTER  XIX. 


Cream. 


When  food  contains  too  little  fat,  or  its  equivalent 
(cream),  we  have  fat-starvation,  which  is  soon  manifested 
by  symptoms  of  rickets.  One  of  the  earliest  symptoms  of 
rickets  is  constipation,  showing  deficient  muscular  tone: 
a  distinct  atony  of  the  bowel. 

This  can  be  remedied  by  the  addition  of  fat  or  cream 
to  the  food.  Some  children  are  benefited  by  giving  them 
codliver-oil,  butter,  or  olive-oil.  Some  authors  advise  giv- 
ing fried  bacon  to  very  young  children;  thus  it  is  plain 
that  each  one  desires  to  remedy  the  deficiency  of  fat  in 
his  own  manner. 

In  buying  cream  from  small  milk-stores  one  can  make 
a  rough  guess  at  the  proportion  of  fat  in  cream  by  its 
thickness.  A  50-per-cent.  cream  at  the  ordinary  tem- 
perature of  the  room  runs  from  a  jug  slowly  and  in  a 
thick  stream,  almost  like  thick  mucilage,  whereas  a  16- 
per-cent.  cream  runs  almost  as  freely  as  milk.  This  is, 
however,  a  crude  way  of  estimating  the  difference  be- 
tween poor  and  rich  cream.  It  is  a  very  important  point 
to  know  exactly  what  percentage  of  cream  we  are  using, 
for  such  mixtures  like  Biedert's,  in  which  1  ounce  of 
cream  is  mixed  with  3  ounces  of  water,  may  agree  very 
well  when  we  use  a  16-  or  20-per-cent.  cream,  but  might 
be  disastrous  if  we  use  a  cream  containing  40  per  cent, 
of  fat.  Such  infants  would  not  tolerate  this  rich  cream, 
and  might  have  troublesome  vomiting. 

CREAM    FOR    HOME-MODIFICATION. 

Ordinary  Cream.- — This  is  made  by  setting  milk  at 
night  and  skimming  it  in  the  morning;    it  is  called  grav- 
ity, or  skimmed,  cream,  and  contains  16  per  cent,  of  fat. 
(134) 


CREAM.  135 

Twelve-per-cent.  Cream.  —  Obtained  in  the  city  by 
using  equal  parts  of  ordinary  (20-per-cent.)  centrifu- 
gal cream  and  plain  milk.  In  the  country  we  must  use 
2  parts  of  ordinary  skimmed,  or  gravity,  cream  (16  per 
cent.)  with  1  part  of  plain  milk,  or  by  taking  the  top 
layer  of  milk,  after  it  has  stood  five  or  six  hours,  by  means 
of  siphoning. 

EigM-per-cent.  cream  is  obtained  in  the  city  by  dilut- 
ing 1  part  of  centrifugal  (20-per-cent.)  cream  with  3 
parts  of  plain  milk;  in  the  country,  by  using  1  part  of 
gravity  cream  and  2  parts  of  plain  milk,  or  by  using  the 
top  layer  of  milk  that  has  been  standing  five  or  six  hours, 
siphoning  it  off. 

Top-milk  is  obtained  directly  from  fresh  milk  by  the 
so-called  "gravity  process."  Cream  contains  a  great  deal 
of  fat,  usually  three-fifths  of  cream  is  fat;  this  floats  on 
the  surface  of  the  watery  milk.  If  a  quart  bottle  of  the 
average  city  milk  is  put  into  ice-water  or  upon  ice  in  the 
refrigerator,  and  removed  after  four  or  five  hours,  we  can 
skim  off  from  the  top  about  10  ounces  of  an  8-per-cent. 
cream;  after  six  hours  about  6  ounces  of  12-per-cent. 
cream.  This  I  shall  speak  of  as  top-milk.  Frequently, 
instead  of  skimming  the  cream,  the  lower  portion  is  si- 
phoned off,  leaving  the  cream  in  the  glass  bottle.  When 
cream  is  removed  by  a  centrifugal  machine,  it  is  known 
as  centrifugal  cream.  It  can  be  separated  much  more 
quickly  than  so-called  gravity  cream,  which  must  rise 
naturally  and  slowly  from  milk  that  is  allowed  to  stand. 

HOW    TO    PKOCUKE    CKEAM. 

Set  aside  the  ordinary  quart  bottle  of  milk  on  the  ice 
for  several  hours  (from  six  to  eight  hours)  to  allow  the 
cream  to  rise.  After  the  cream  has  risen  draw  the  milk 
from  the  bottom  of  the  bottle;  this  can  be  accomplished 
by  means  of  a  siphon. 

To  make  the  siphon  get  a  piece  of  glass  tubing  21 
inches  in  length  and  a  quarter  of  an  inch  in  calibre.    This 


136  INFANT-FEEDING. 

can  be  procured  in  any  drug-store.  German  glass  is  less 
liable  to  crack  than  American  glass.  If  the  glass  tubing 
is  longer  than  21  inches  make  a  small  scratch  in  it,  after 
measuring  off  21  inches,  with  a  three-cornered  file;  then 
grasp  the  glass  tubing  between  the  fingers  and  opposing 
thumbs  of  both  hands,  having  the  thumb-nails  touching 
each  other  on  the  side  of  the  glass  just  opposite  to  the 
scratch.  On  attempting  to  bend  the  glass  tube  it  will 
break  smoothly  across,  and  if  there  are  any  sharp  edges 
they  can  be  smoothed  by  rubbing  them  down  with  the 
file. 

To  bend  the  glass  tube  to  the  V  shape,  hold  it  in 
the  flame  of  an  ordinary  gas-jet  or  alcohol-lamp  for  a 
few  moments,  twirling  the  glass  rod  until  it  softens  suf- 
ficiently to  allow  it  to  be  bent  to  the  required  angle.  The 
tube  should  be  warmed  gradually  at  first,  and  then  put 
right  into  the  flame.  It  is  better  in  bending  the  glass 
to  make  one  arm  of  the  siphon  a  few  inches  longer  than 
the  other. 

In  using  the  siphon  hold  it  with  the  angle  down,  fill 
it  with  water,  and  close  the  long  arm  with  the  tip  of  the 
finger;  then,  keeping  the  finger  applied  to  the  long  end, 
turn  the  siphon  with  the  angle  up,  and  introduce  the  short 
arm  into  the  bottle  of  milk,  letting  it  rest  upon  the  bot- 
tom. On  removing  the  finger,  the  milk  will  flow  through 
the  tube,  and  continue  to  do  so  until  the  bottle  is  empty. 
It  is,  therefore,  necessary  to  watch  the  layer  of  cream,  so 
that  the  siphon  can  be  lifted  out  of  the  bottle  just  before 
the  cream  reaches  it.  There  will  thus  remain  in  the  milk- 
bottle  all  of  the  cream  and  a  small  portion  of  the  milk, 
the  latter  depending  upon  the  expertness  of  the  person 
using  the  siphon. 

TO    PASTEURIZE    THE    CKEAM. 

Take  a  clear  glass  bottle  having  a  neck  not  very  wide ; 
fit  into  the  same  a  perforated  cork  with  a  chemical  ther- 
mometer registering  up  to  212°  F.    The  bulb  of  the  ther- 


MODIFICATION    OF    MILK.  137 

mometer  should  come  within  half  an  inch  of  the  bottom 
of  the  bottle.  The  cream  is  put  into  the  bottle,  and  the 
cork  carrying  the  thermometer  is  inserted;  the  bottle  is 
then  placed  in  a  pot  containing  a  couple  of  inches  of 
warm  water  and  allowed  to  heat  on  the  stove.  The  ther- 
mometer should  be  watched  until  it  reaches  160,  taking 
care  that  it  does  not  go  above  170.  When  the  thermom- 
eter has  reached  this  point,  set  the  pot  back  on  the  stove 
where  it  will  cool  off,  and  allow  it  to  remain  there  for 
twenty  minutes.  At  the  end  of  this  time  substitute  a 
plug  of  absorbent  cotton  for  the  cork  containing  the  ther- 
mometer. Great  care  must  be  taken  to  keep  the  absorbent 
cotton  dry.  Cream  thus  prepared  is  pasteurized,  and  will 
keep  sweet  and  fresh  for  twenty-four  hours  without  being 
kept  on  ice,  and  all  that  is  necessary  in  removing  a  por- 
tion from  the  bottle  is  to  be  sure  that  the  cotton  plug 
does  not  become  moist,  or,  if  it  should,  to  replace  it  with 
a  dry  piece  at  once. 

TO    CLEAN    THE    GLASS    SIPHON. 

It  is  advised  to  fill  it  with  water  immediately  after 
using  it,  and  the  ordinary  tube-brush  having  eighteen 
inches  of  wire  added  to  it  will  permit  thorough  cleansing. 
Nothing,  however,  will  be  found  as  good  as  thorough 
boiling  in  plain  water  to  which  a  pinch  of  soda  has  been 
added. 

Modification  of  Milk. 

It  has  been  shown  previously  that  the  percentages  of 
fat  in  woman's  and  in  cows'  milk  are  about  the  same,  that 
the  quantity  of  sugar  is  rather  lower  in  cows'  milk,  and 
that  the  quantity  of  casein  and  albumin  is  greater  in 
cows'  milk,  as  is  also  that  of  the  ash.  Experience  has 
shown  that  cows'  milk  must  be  diluted  before  it  can  safely 
be  fed  to  infants.  Simply  diluting  the  milk  reduces  the 
percentages  of  fat  and  sugar  too  much;  so  the  practice  of 
adding  cream  and  sugar  has  arisen,  but  the  processes  that 


138  INFANT-FEEDTNO. 

liave  been  advocated  for  obtaining  the  desired  additional 
quantities  of  fat  and  sugar  have  been  too  complicated  for 
general  nse. 

The  top  9  ounces  of  a  quart  of  milk  on  which  the 
cream  has  risen  will  be  about  three  times  as  rich  in  fat 
as  the  whole  milk,  the  top  15  or  16  ounces  will  be  about 
twice  as  rich  as  the  whole  milk,  while  the  other  ingredi- 
ents remain  about  the  same  as  in  whole  milk. 

For  babies  under  3  months  of  age  the  top  9  ounces 
of  a  quart  of  milk  on  which  the  cream  has  risen  should 
be  diluted  from  3  to  10  times  and  1  part  of  sugar  added 
to  25  parts  of  food. 

For  babies  3  to  6  months  old  the  top  16  ounces  of 
a  quart  of  milk  on  which  the  cream  has  risen  should  be 
diluted  2  or  3  times  and  1  part  of  sugar  added  to  25  or 
30  parts  of  food.. 

For  babies  6  to  9  months  old  the  top  20  ounces  of 
a  quart  of  milk  on  which  the  cream  has  risen  should  be 
diluted  1/2  to  1  time  and  1  part  of  sugar  added  to  50 
parts  of  food.  An  even  tablespoonful  of  granulated  sugar 
equals  1/2  ounce. 

By  following  this  method  the  infant  commences  on 
weak  mixtures  that  show  about  the  same  composition  and 
variations  as  mothers'  milk  and  gradually  takes  food  richer 
in  casein  until  plain  milk  is  reached. 

The  diluents  used  are  water,  gruels,  or  dextrinized 
gruels,  which  are  simply  ordinary  gruels  the  starch  of 
which  has  been  converted  into  soluble  forms,  leaving  the 
cellulose  and  proteids  of  the  cereal  in  a  finely  divided 
state.  The  effect  of  the  different  diluents  will  be  men- 
tioned farther  on. 

MILK-SUGAR  SOLUTIONS. 

1.  Take  1  ounce  of  milk-sugar  and  20  ounces  ~| 

of  water,  and  dissolve.  I  This  makes  about  a 

Or  1   even  tablespoonful  of  milk-sugar  and   y      5  -  per  -  cent,  sugar 

7  V2  tablespoonfuls   of  water,  and   dis-  solution. 

solve. 


MODIFICATION    OF    MILK.  139 

2.  Dissolve  1  tablespoonful  of  milk-sugar  in  "| 

6  Va  ounces  of  water.  I  Makes    a    6-per-cent. 

Or  1   ounce  of  sugar  is  to  be  dissolved  in    [       sugar  solution. 
16  V2  ounces  of  water. 

3.  Dissolve  1  ounce  of  sugar  in  14  ounces  of  ~) 

water.  I   Makes    a    7-per-cent. 

Or   1   even  tablespoonful  in  5  Vs  ounces  of   [       sugar  solution, 
water. 

4.  Dissolve  1  ounce  of  sugar  in  12  1/2  ounces 

of  water.  I  Makes  an  8-per-cent. 

Or   1  even  tablespoonful  in  41/.,   ounces    of    (      sugar  solution, 
water. 

5.  Double  the  strength  of  above  milk-sugar  ")   Makes  a  10-per-cent. 

(Formula  No.  1).  j       sugar  solution. 

ADDITION    OF    SUGAR    TO    MILK. 

In  order  to  render  milk  palatable,  sugar  must  be  added 
in  some  form;  hence  cane-sugar  or  milk-sugar  has  been 
advised.  Jacobi  insists  on  the  addition  of  cane-sugar,  and 
he  agrees  with  Biedert,  who  uses  it  in  his  cream-mixture. 
That  cane-sugar  certainly  has  some  virtue  can  be  seen  by 
the  fact  that  it  is  used  extensively  as  a  preservative  in  the 
manufacture  of  condensed  milk. 

Cane-sugar.  —  Cane-sugar,  being  far  sweeter  than 
sugar  of  milk,  it  is  advisable  to  use  1/2  the  quantity  that 
would  ordinarily  be  used  for  sweetening  with  milk-sugar. 
Cane-sugar  is  advised  in  the  treatment  of  constipation; 
frequently  we  find  breast-fed  babies  who  suffer  constipa- 
tion, the  cause  being  deficiency  in  sugar.  In  such  cases 
giving  a  small  lump  (about  1/2  teaspoonful)  of  cane- 
sugar  dissolved  in  a  teaspoonful  of  sterile  water  (ordinary 
boiled  water),  and  this  given  immediately  before  putting 
the  baby  to  the  breast,  will  make  up  the  deficient  sugar 
and  frequently  modify  a  distressing  constipation  without 
resorting  to  drugs. 

C ontra-indications  to  the  Use  of  Sugar. — There  are 
a  great  many  conditions  in  which  the  addition  of  sugar 
is  not  only  contra-indicated,  but  absolutely  harmful.     For 


140  INFANT-FEEDING. 

example:  If  an  infant  suffers  with  colic  and  lias  sudden 
attacks  (paroxysms)  of  pain  which  disturb  the  infant's 
sleep,  such  an  infant  will  be  found  with  its  legs  drawn 
up  to  its  belly,  and  besides  it  will  utter  shrieks  while 
crying.  The  stools  will  usually  be  green  and  sour  smell- 
ing, and  the  abdomen  will  be  found  greatly  distended 
with  gas  from  fermentation,  and  frequently  the  infant 
will  have  violent  eructations.  Such  an  infant  usually 
receives  an .  excess  of  sugar.  The  treatment  of  such  a 
case  is  the  absolute  discontinuance  of  susrar  in  the  food. 


HOW    SHALL    WE    SWEETEN 


If  constipation  has  accompanied  the  infant's  ferment- 
ative condition  and  has  also  preceded  this  attack  of  colic, 
then  I  advise  adding  glycerin  to  the  milk.  It  has  a  very 
sweet  taste  and  a  pronounced  laxative  effect. 

Dose  of  Glycerin. — For  some  children  half  a  tea- 
spoonful  of  glycerin  added  to  each  bottle  will  suffice; 
for  others,  I  frequently  use  1  teaspoonful  to  each  bottle, 
rarely  more.  Glycerin  has  a  pronounced  antifermentative 
effect;  being  an  oil,  it  is  indicated  in  children  requiring 
the  addition  of  fat.  It  certainly  has  decided  nutritive 
properties. 

SOLUTIONS    USED    FOR    RENDERING    COWS'    MILK 
ALKALINE. 

Lime-water  is  the  alkali  usually  selected  for  neutral- 
izing the  acidity  in  cows'  milk.  It  acts  by  partly  neutral- 
izing the  acid  of  the  gastric  juice,  so  that  the  casein  is 
coagulated  gradually  and  passes,  in  great  part,  unchanged 
into  the  intestine,  to  be  there  digested  by  the  alkaline 
secretions.  As  it  contains  only  1/2  grain  of  lime  to  the 
fluidounce,  the  desired  result  cannot  be  attained  unless 
at  least  a  third  part  of  the  milk-mixture  be  lime-water. 
Instead  of  lime-water,  2  to  4  grains  of  bicarbonate  of 
sodium  may  be  added  to  each  bottle,  or,  better  still,  from 
5  to  15  drops  of  the  saccharated  solution  of  lime. 


MODIFICATION    OF    MILK.  141 

This  solution  is  made  in  the  following  way: — 

IJ  Slaked  lime,  1  ounce. 

Refined  sugar,  in  powder,  2  ounces. 
Distilled  water,  1  pint. 

Mix  the  lime  and  sugar  by  trituration  in  a  mortar. 
Transfer  the  mixture  to  a  bottle  containing  the  water, 
and,  having  closed  this  with  a  cork,  shake  it  occasionally 
for  a  few  hours.  Finally  separate  the  clear  solution  with 
a  siphon  and  keep  it  in  a  stoppered  bottle. 

Bicarbonate-of-Soda  Solution  (Baking-soda). — Take 
1  grain  of  soda  bicarbonate  to  1/2  ounce  of  water.  Or 
1  drachm  of  soda  bicarbonate  to  1  quart  of  water.  This 
is  the  proper  strength  used  for  diluting  milk. 

Quantity  to  be  Used. — One  tablespoonful  of  the  last- 
named  solution  equals  in  strength  1  tablespoonful  of  ordi- 
nary lime-water. 

Both  lime-water  and  soda-bicarbonate  solution  should 
be  kept  in  very  clean,  well-stoppered  bottles  and  in  a  cool 
place. 

The  writer  has  seen  better  results  by  using  bicarbonate 
of  potassium  (11  per  cent.)  solution.  The  addition  of  a 
half-teaspoonful  to  each  feeding-bottle  is  well  borne  and 
beneficial  where  tendency  to  colic  exists. 


CHAPTER  XX. 

Water. 

Or  all  the  necessities  of  an  infant,  water  stands  out 
most  prominently.  It  will  aid  materially  in  clearing  the 
mouth  and  gums  and  in  quenching  the  thirst.  It  is  cer- 
tainly diuretic,  and  water  given  regularly  is  one  of  our 
best  laxatives.  It  is  a  good  rule,  and  one  that  I  insist 
upon,  namely:  to  instruct  every  mother  and  nurse  that 
a  child,  young  or  old,  must  receive  water  several  times  a 
day. 

Quantity. — An  infant  up  to  the  first  month  shall  re- 
ceive several  teaspoonfuls  of  plain  sterile  (boiled)  water, 
which  has  been  allowed  to  cool,  but  by  no  means  ice- 
water. 

This  drink  of  water  is  best  given  either  immediately 
after  nursing  or  feeding  or  as  soon  after  the  feeding  as 
possible. 

It  is  not  necessary  to  awaken  the  child  to  give  it  a 
drink,  but  if  it  is  not  time  for  feeding  and  the  infant  is 
restless,  a  few  spoonfuls  of  cool  water  will  frequently  com- 
fort it. 

When  we  desire  to  modify  constipation,  then  water 
will  be  a  most  important  factor,  especially  so  when  large, 
cheesy  curds  are  found  in  the  stool. 

Instances  will  be  found  in  which  some  children  will 
refuse  water;  in  such  cases  the  addition  of  a  few  grains 
of  granulated  (cane-)  sugar  will  prove  advantageous. 
Older  children,  over  six  months  old,  can,  if  properly  de- 
veloped, take  hold  of  a  glass  and  be  guided  in  the  drink- 
ing or  sipping  of  a  wineglassful  of  water.  I  advise  giving 
at  least  3  wineglassfuls  of  plain  sterile  (boiled)  water  per 
day,  especially  during  warm  weather. 
(142) 


WATER.  143 

The  free  dilution  of  children's  nourishment  with  water 
is  demanded  upon  the  following  additional  facts:  Only 
to  a  certain  limit  will  pepsin  be  furnished  for  digestive 
purposes.  Probably  a  portion  of  this  is  not  entirely  util- 
ized. A  great  quantity  of  water  is  necessary  to  assist  in 
pepsin  digestion.  In  artificial  digestion  albumin  often 
remains  unchanged  until  large  quantities  of  acidulated 
water  are  supplied.  Without  doubt  many  disturbances 
of  digestion  are  to  be  explained  by  a  deficiency  of  water, 
certainly  many  more  than  are  due  to  an  excess  of  it,  as 
it  is  so  quickly  absorbed. 


CHAPTER  XXI. 

Bottle-feeding,  ok  Hand-feeding. 

Cleanliness. — The  most  important  point  to  remember 
is  that  everything  used  in  connection  with  "hand-feeding" 
must  be  scrupulously  clean. 

To  sterilize  milk  in  a  filthy  bottle,  or  to  put  milk 
contaminated  with  stable  filth  or  dirt  from  the  udder  of 
a  cow,  or  milk  containing  pathogenic  bacteria,  into  an 
absolutely  clean  bottle,  is  surely  repulsive. 

Therefore,  my  first  proposition  is:  "Clean  everything 
that  is  associated  with  infant-feeding,"  from  the  milking 
of  the  cow,  the  surroundings  of  the  cow,  until  the  food 
is  ready  to  be  fed  to  our  infants.  This  necessarily  implies 
quite  an  amount  of  work,  which  I  shall  endeavor  to  detail 
later  on. 

Amount  to  be  Fed.  —  Ssnitkin  (investigations  at  the 
Children's  Hospital  of  St.  Petersburg,  quoted  by  Eotch) 
makes  the  following  rule:  "The  greater  the  weight,  the 
greater  the  gastric  capacity." 

Ssnitkin's  table  of  calculation  shows  that  one  one- 
hundredth  of  the  initial  weight  should  be  taken  as  the 
figure  with  which  to  begin  the  computation,  and  to  this 
should  be  added  one  gramme  for  each  day  of  life. 


Illustration  of  Ssnitkin's  Rule. 


Initial 
Weight. 

3000  Gm. 
4000  Gm. 
5600  Gm. 


Early  Days. 

30  Gm. 
(About  1  oz.) 

45  Gm. 
(About  lioz.) 

60  Gm. 
(About  2  oz. ) 


At  15  Days. 

30  + 15  =  45  Gm. 

(About  lh  oz.) 
45  +  15  =  60  Gm. 

(About  2  oz. ) 
60  + 15  =  75  Gm. 

(About  2£  oz.) 


At  SO  Days. 

30  +  30  =  60Gm. 

(About  2  oz. ) 
45  + 30  =  75  Gm. 

(About  21  oz.) 
60  +  30  =  90  Gm. 

(About  3  oz. ) 


(144) 


CHAPTER  XXII. 


Feeding-table  and  Cream-mixtures. 


Age. 

Intervals 
of  Feeding. 

Number 
of  Times 

IN 

24  Hours. 

Average 
Amount 

Each 
Feeding. 

Average  in 
24  Hours. 

1st  -week .... 
1st  month  .    .    . 
2d  month  .    .    . 
3d  and  4th  mos. 
5th  and  6th  mos. 

2    hours 

2  hours 
2J  hours 

3  hours 
3    hours 

10 

8 
8 
7 
6 

1  oz. 
l£  to  2  oz. 

3  to  4  oz. 

4  to  5  oz. 
6    to  7  oz. 

10  oz. 
12  to  16  oz. 
20  to  30  oz. 
30  to  35  oz. 
34  to  40  oz. 

The  above  is  the  feeding-table  of  George  C.  Carpenter 
(London). 

biedert's  cream-mixtures. 

The  following  formulae  are  from  the  fourth  edition 
of  his  book  on  "Infant-feeding,"  published  in  1900: — 

Formula.    Cream.     Water.     Milk-sugar.    Milk.    Casein.     Fat.     Sugar. 

Per  Cent.  Per  Cent.  Per  Cent. 

12  oz.  Q  dr.  .    . 

12  oz.  4|  dr. 

12  oz.  4}  dr. 

12  oz.  4|  dr. 

12  oz.  4,\  dr. 

8  oz.  3    dr. 


I. 

II. 
III. 
IV. 

V. 
VI. 


4  oz. 

4  Oil. 

4  oz. 
4  oz. 
4  oz. 


2oz. 

4  oz. 

8oz. 
12  oz. 
24  oz. 


0.9 
1.2 
1.4 
1.7 
2.0 
2.5 


2.5 
2.6 
2.7 
2.9 
3.0 
2.7 


Cream.  Milk.    Water. 


Milk- 
sugar. 


Casein.     Fat.     Sugar. 

Per  Cent.  Per  Cent.  Per  Cent. 


1. 

1st  mo. 

giv. 

No. 

I*ij. 

2. 

2d  mo. 

No. 

SiJ- 

No. 

3. 

3d  mo. 

No. 

giv. 

No. 

4. 

4th  mo. 

No. 

gviij. 

No. 

5. 

5th  mo. 

No. 

3*ij. 

No. 

6. 

6th  mo. 

No. 

5*vj. 

Sviij 

-  Is  equiv-  1  0 

^ss-  alent  to  1U 

N  Is  equiv-  1  4 

JN0-  alent  to  x'* 

No.  Is,eq«;v-  1.8 
alent  to 

No-  'iTlo"  ™ 

No-  ISt  " 


2.4 
2.6 

2.7 
2.9 
3.0 
3.0 

(145) 


3.8 
3.8 
3.8 
3.8 
3.7 
4.0 


146  INFANT-FEEDING. 

The  latter  are  known  as  Biedert's  cream-mixtures,  and 
are  quoted  by  A.  Jacobi.44 

According  to  recent  milk-analyses,  it  is  necessary  to 
take  6  per  cent.,  which  is  equivalent  to  5  1/2  drachms  of 
sugar  to  12  ounces  of  water.  It  has  also  been  shown  that 
cane-sugar  in  the  same  quantity  as  milk-sugar  can  be  used. 
In  using  Formula  5,  especially  if  an  infant  is  constipated, 
it  is  advisable  gradually  to  substitute  milk  for  the  water; 
thus  we  take  away  1  ounce  of  water,  and  add  1  ounce  of 
milk,  until  our  formula  is: — 

Cream.  Sugar-water.  Milk. 

4  ounces.  4  ounces.  20  ounces. 

and  gradually  arrive  at  a  whole-milk  feeding;  in  other 
words,  give  pure  cows'  milk  undiluted.  Biedert  claims 
that  frequently  diluted  cows'  milk  was  not  well  borne, 
especially  on  weak  stomachs,  and  the  change  to  the  cream- 
mixture  resulted  in  decided  benefit.  Moreover,  he  be- 
lieves that  the  cream-mixture  is  assimilated  far  better  than 
the  diluted  milk-mixtures  not  containing  cream. 

Thus  he  claims  that  the  cases  of  constipation  alter- 
nating with  diarrhoea  and  lastly  mucous  enteritis  are  those 
in  which  the  cream-mixture  will  render  satisfaction;  but 
he  advises  that  a  definite  rule  must  prevail  regarding  the 
amount  of  fat  contained  in  the  cream,  and  furthermore 
that  an  8-  to  10-per-cent.  cream  be  used. 

biedert's  directions  for  making  his  cream. 

From  1  to  2  quarts  of  milk  are  put  into  a  broad  jar 
(glass)  on  the  ice,  for  no  longer  than  two  hours.  He  then 
removes  with  a  flat  spoon  from  3  1/2  to  7  ounces  of  the 
thin  white  creamy  layer  over  the  bluish  mass  of  milk.  In 
removing  the  above  quantity  a  small  portion  of  the  milk 
will  be  removed  with  it.  In  cases  of  severe  constipation 
Biedert  insists  on  removing  pure  cream. 


'Therapeutics  of  Infancy  and  Childhood." 


CREAM   FEEDING.  147 

The  above  Formula  I  is  for  the  first  month,  Formula 
II  is  .for  the  second  month,  Formula  III  is  for  a  child 
from  three  to  four  months,  Formula  IV  is  for  fourth  to 
fifth  month,  Formula  V  is  for  the  sixth  to  seventh  month, 
and  Formula  YI  is  for  the  eighth  to  tenth  month. 

It  is  understood  that,  while  feeding,  the  general 
condition  of  the  child  is  the  criterion,  and  thus  we  shall 
frequently  be  compelled  to  change  the  formula  for  in- 
dividual requirements,  some  infants  requiring  far  more 
cream  than  the  above-mentioned  formulas  give  them  for 
their  age  and  their  weight,  whereas  the  great  majority 
will  require  a  modification  of  far  less  cream  than  the 
above-given  formulae  for  their  age  and  weight. 

The  indiscriminate  feeding  of  cream,  to  strengthen  the 
laby,  cannot  be  too  strongly  condemned.  Many  a  dyspeptic 
owes  his  trouble  to  overfeeding  by  a  too  good  mother  or  nurse. 
When  cream  is  added,  and  the  proportion  of  fat  or  proteid  is 
too  large,  vomiting  will  result.  Stuffing  delicate  children  with 
cream,  regardless  of  their  digestive  power,  cannot  be  too 
strongly  condemned.  When  improper  food  is  given,  and  the 
infant's  stomach  is  overtaxed,  the  excess  of  food  irritates  and 
may  cause  vomiting.  If,  however,  the  food  remains,  then  the 
gastric  mucosa  is  inflamed  by  bacterial  fermentation  of  stag- 
nant food.  This  may  result  in  fermentative  gastritis  and 
cause  chronic  enlargement  of  the  stomach,  or  diarrhoea. 


CHAPTER  XXIII. 

Home-modification  of  Milk, 
coit's  decimal  method  (tuttle,  gallaudet). 

This  is  the  simplest  and  easiest-worked  method  of 
home-modification  yet  suggested.  It  is  based  on  the 
metric  system,  and  all  the  calculations  are  made  in  deci- 
mals. 

Three  solutions  are  required:  1.  A  decimal  (10  per 
cent.)  cream,  or  superfatted  milk  for  introducing  the  fat. 
2.  A  saccharated  (10  per  cent.)  skimmed  milk  for  intro- 
ducing proteids  not  carried  by  the  cream.  3.  A  standard 
(10  per  cent.)  sugar  solution  for  introducing  the  lactose 
not  carried  by  the  cream  or  the  skimmed  milk.  Solutions 
1  and  3  only  are  required  when  the  proteid  percentage 
is  small.  As  the  child  grows  older,  and  a  higher  proteid 
percentage  is  necessary,  solution  2  is  required  also. 

Decimal  cream  is  produced  by  allowing  a  quart  of 
ordinary  fresh  milk  from  a  mixed  herd  to  stand  on  ice 
for  fifteen  hours,  and  at  the  end  of  this  time  one-fifth  of  it 
is  taken  from  the  top.  This  averages  15  per  cent,  of  fat, 
and  loses  about  1/2  per  cent,  each  of  sugar  and  proteids. 
If  to  this  we  add  1/2  its  volume  of  water,  a  decimal  cream 
is  obtained,  analyzing:  10  per  cent,  of  fat,  2.33  per  cent, 
of  proteids,  and  2.66  per  cent,  of  sugar.  From  this  the 
following  formulae,  showing  the  amounts  of  proteids  and 
lactose  coincidently  introduced  with  any  definite  fat-per- 
centage, are  easily  deduced: — 

Decimal  cream  in  introducing  4  per  cent,  of  fat  also 
introduces  1  per  cent,  of  proteids  and  1  per  cent,  of  lac- 
tose. Decimal  cream  in  introducing  3.5  per  cent,  of  fat 
also  introduces  0.8  per  cent,  of  proteids  and  0.9  per  cent. 
(148) 


HOME-MODIFICATION  OF  MILK.  149 

of  lactose.  Decimal  cream  in  introducing  3  per  cent,  of 
fat  also  introduces  0.7  per  cent,  of  proteids  and  0.8  per 
cent,  of  lactose.  Decimal  cream  in  introducing  2.5  per 
cent,  of  fat  also  introduces  0.6  per  cent,  of  proteids  and 
O.Y  per  cent,  of  lactose.  Decimal  cream  in  introducing  2 
per  cent,  of  fat  also  introduces  0.5  per  cent,  of  proteids 
and  0.5  per  cent,  of  lactose. 

Saccharated  shimmed  milk  depends  on  the  fact  that 
skimmed  milk  analyzes  4  per  cent,  of  proteids  and  5  per 
cent,  of  sugar.  Five  per  cent,  more  of  lactose  is  added 
simply  for  convenience  of  calculation.  This  means  add- 
ing 1  ounce,  by  weight,  of  lactose  to  20  ounces  of  skimmed 
milk.  Our  solution  then  analyzes:  proteids,  4  per  cent.; 
and  lactose,  10  per  cent.  If  we  wish  to  add  1  per  cent, 
of  proteids,  we  use  one-fourth  of  the  total  food  required 
from  solution  2;  if  0.5  per  cent,  of  proteids,  one-eighth, 
etc.,  always  remembering  that  we  introduce  coincidently 
two  and  one-half  times  as  much  sugar.  The  f ormulse  here 
deduced  are  also  plain: — 

Amount  of  food  in  cubic  centimetres  X  1/8  (saccha- 
rated skimmed  milk)  adds  proteids,  0.5  per  cent.;  and 
lactose,  1.25  per  cent.  Amount  of  food  in  cubic  centi- 
metres X  V4  (saccharated  skimmed  milk)  adds  proteids, 
1  per  cent.;  and  lactose,  2.5  per  cent.  Amount  of  food 
in  cubic  centimetres  X  3/8  (saccharated  skimmed  milk) 
adds  proteids,  1.5  per  cent.;  and  lactose,  3.75  per  cent. 
Amount  of  food  in  cubic  centimetres  X  1/2  (saccharated 
skimmed  milk)  adds  proteids,  2  per  cent.;  and  lactose,  5 
per  cent. 

Standard  sugar  solution  is  prepared  by  dissolving  10 
per  cent,  of  lactose  in  sterile  water,  or  2  ounces,  by  weight, 
in  20  ounces  of  water. 

In  calculating  f ormulse  four  facts  only  are  necessary: 
the  quantity  of  food  required;  the  percentage-formulas 
required;  that  the  standards,  except  the  proteids,  are  10 
per  cent.;  and  the  quantity  of  other  constituents  intro- 
duced with  the  standards. 


150  INFANT-FEEDING. 

With  these  facts  in  mind,  all  that  is  necessary  further 
is  to  reduce  the  quantity  expressed  in  ounces  to  cubic 
centimetres  by  multiplying  by  thirty,  and  to  multiply  this 
product  by  one-tenth  of  the  constituent  to  be  introduced. 
Examples  with  and  without  the  introduction  of  extra  pro- 
teids  will  be  given: — 


Single  Feeding. 

Fat.     Proteids.  Sugar. 

Per  Cent.    Per  Cent.  Per  Cent. 

Quantity,  2  oz.    Formula  desired 2.0  0.50  6.00 

Oz.    2  X  30  =  60    c.cms.  X  0.2  =  12    c.cms. 

decimal  cream,  adds 2.0  0.50  0.50 

Leaves    0.0  0.00  5.50 

Oz.  2  X  30  =  60  c.cms.  X  0.55  =  33  c.cms. 

sugar  solution,  adds 5.50 

Working  formula:     12  c.cms.  decimal  cream. 

33  c.cms.  standard  sugar  solution. 
15  c.cms.  water. 

60  c.cms. 


One  Day's  Food. 

Fat.  Proteids.    Sugar. 

Per  Cent.  Per  Cent.    Per  Cent. 

Quantity,  35  oz.    Formula  desired 4.0  1.0  6.50 

Oz.  35  X   30  =  1050  c.cms.  X   0.4  =  420 

c.cms.  decimal  cream,  adds 4.0  1.0  1.00 

Leaves    0.0  0.0  5.50 

Oz.  35  X  30  =  1050  c.cms.  X  0.55  =  577.50 

c.cms.  sugar  solution,  adds 5.50 

Working  formula:     420.00  c.cms.  decimal  cream. 

577.50  c.cms.  standard  sugar  solution. 
52.50  c.cms.  water. 

1050.00  c.cms. 


GENERAL  RULES  FOR  BOTTLE-FEEDING.  151 

One  Feeding. 

Fat.  Proteids.  Sugar. 

Per  Cent.  Per  Cent.  Per  Cent. 

Quantity,  5  oz.     Formula  desired 4.0           1.50  7.00 

Oz.  5  X  30  =  150  c.cms.  X  0.4  =  60  c.cms. 

decimal  cream,  adds 4.0           1.00  1.00 

Leaves    0.0  0.50  6.00 

Oz.  5  X  30  =  150  c.cms.  X  h  =  18.75  c.cms. 

skimmed  milk,  adds 0.0  0.50  1.25 

Leaves    0.0  0.00  4.75 

Oz.  5X30  =  150  c.cms.  X  0.475  =  71.75 

c.cms.  sugar  solution,  adds 4.75 

Working  formula:     60.00  c.cms.  decimal  cream. 

18.75  c.cms.  saccharated  skimmed  milk. 
71.25  c.cms.  standard  sugar  solution. 

150.00  c.cms. 
General  Rules  for  Bottle-feeding. 


Age  of 
Child. 

Frequency 
or  Interval, 
of  Feeding. 

Number  of 

Feedings  in 

24  Hours. 

Average 

Amount  for 

Each 

Feeding. 

Average 
Amount  in 
24  Hours. 

From  its 

birth  until  it 

is  1  month 

old. 

2  hours. 

10 

1  to  2  ounces. 

10  to  20 
ounces. 

1  month 

until 
2  months. 

Every 
2|  hours. 

8 

2  to  2J 
ounces. 

16  to  24 
ounces. 

2  to  4 
months  old. 

Every 
3  hours. 

6  or  7 

3£  to  4 
ounces. 

20  to  26 
ounces. 

4  to  6 
months  old. 

Every 
3  hours. 

6 

5  or  6  ounces. 

30  or  36 
ounces. 

6  to  9 

months  old. 

Every  3J  to 
4  hours. 

5 

8  ounces. 

40  ounces. 

9  to  12 
months  old. 

Every 
4  hours. 

5 

8  ounces. 

40  ounces. 

152  infant-feeding. 

Rules  for  Feeding. 

For  a  Child  at  Birth.  Formula  1.— The  newborn 
infant's  food  should  consist  of  (home-modification): — 

Fat 1.0        Cream  . . , 2      ounces. 

Sugar   5.0        Milk    2       ounces. 

Proteids 0.75       Lime-water    1       ounce. 

Reaction  alkaline.       Water  15       ounces. 

Milk-sugar    6%  drachms. 

The  above  formula  (1)  is  to  be  divided  into  10  feed- 
ings of  2  ounces  each,  or  60  cubic  centimetres  each,  and 
should  be  heated  for  20  minutes  to  16 7°  F.,  though  Prof. 
Russell,  of  Wisconsin,  has  proved  by  experiment  that 
tubercle  bacilli  is  destroyed  at  140°  F.,  which  temperature 
may  answer  when  a  good  source  of  milk  is  found. 

The  cream  must  contain  at  least  10  per  cent,  of  fat. 
This  is  known  as  a  decimal  cream,  and  can  be  referred  to 
under  the  heading  of  "Cream  for  Home-modification." 

Formula  for  Home  Use. 

Child  1  Month.     Formula  2. — Take  of: — 

Fat 2.0  Cream   4       ounces. 

Sugar   5.0  Lime-water    1       ounce. 

Proteids 0.75  Water    15-25       ounces. 

Lime-water.  .  .5.0  Milk-sugar     6%  drachms. 

The  above  quantity  is  to  be  divided  into  ten  feed- 
ings, and  heated  for  20  minutes  to  167°  F.,  and  the  in- 
fant to  be  fed  once  every  two  hours.  In  Formula  2  we 
have  added  more  cream  and  purposely  left  out  the  milk. 
If  the  infant  thrives  on  this  mixture,  then  we  can  sub- 
stitute 1  ounce  of  milk  instead  of  1  ounce  of  water.  Some 
children  will  not  be  satisfied  with  less  than  3  to  4  ounces; 
there  is  no  reason  why  they  should  not  receive  the  above 
quantity  if  their  general  condition  warrants  it. 

After  the  end  of  the  second  month  the  quantity  of 
food  can  be  increased  if  the  infant's  appetite,  sleep,  stools, 
and  general  condition  warrant  it.     Thus,  instead  of  feed- 


SCHEDULE  FOR  FEEDING  AND  FORMULA. 


153 


6 

H 

< 

"A 

H 
Ph 

e5 

P  « 

02  H 

to  B 

0  85 

-  'A 
PhPh 

i. 

1st  and  2d  day. 

5.0 

4-8 

125-250 

ii. 

3d  to  7tb  day. 

2.0 

6.0 

'  0.60  ' 

10-15 

310-460 

in. 

.  2  to  4  weeks. 

2.5 

6.0 

0.80 

20-30 

620-930 

IV. 

1  to  3  months. 

3.0 

6.0 

1.00 

22-36 

680-1110 

V. 

3  to  4  months. 

3.5 

6.0 

1.25 

28-38 

870-1180 

VI. 

4  to  6  months. 

4.0 

6.0 

1.50 

32-38 

990-1180 

VII. 

6  to  9  months. 

4.0 

7.0 

2.00 

34-42 

1050-1300 

VIII. 

9  to  12  months. 

4.0 

6.0 

2.50 

38-45 

1180-1400 

IX. 

12  to  15  months. 

4.0 

5.0 

3.00 

40-50 

1240-1550 

X. 

15  to  18  months. 

4.0 

5.0 

3.50 

45-50 

1400-1550 

XI. 

18  months 

(whole  milk). 

3.5 

4.3 

4.00 

45-50 

1400-1550 

Formula  Obtained  by  Diluting  12-per-cent.  Cream. 


Dil.  5  times  with  6-per-cent.  sugar  sol. : 
Dil.  4  times  with  6-per-cent.  sugar  sol. : 
Dil.  3  times  with  7-per-cent.  sugar  sol.: 
Dil.  2jt  times  with  7-per-cent.  sugar  sol. : 
Dil.  2  times  with  7-per-cent.  sugar  sol. : 

By  diluting  five  times  is  meant  one  part  of  the  cream  and  five 
parts  of  the  sugar  solution,  etc. 


Fat. 

Sugar. 

Proteids 

Per  Cent 

Per  Cent. 

Per  Cent. 

II. 

2.0 

6 

0.60 

III. 

2.5 

6 

0.80 

IV. 

3.0 

6 

1.00 

V. 

3.5 

6 

1.20 

VI. 

4.0 

6 

1.30 

Formula  Obtained  by  Diluting  8-per-cent.  Cream. 


Dil.  once  with  10-per-cent.  sugar  sol.: 
Dil.  1 J  times  with  7-per-cent.  sugar  sol. : 
Dil.  3  times  with  7-per-cent.  sugar  sol. : 
Dil.  7  times  with  5-per-cent.  sugar  sol. : 


Fat. 

Sugar. 

Proteids 

Per  Cent 

.  Per  Cent. 

Per  Cent. 

VII. 

4 

7 

2.00 

XII. 

3 

6 

1.50 

XIII. 

o 

6 

1.00 

XIV. 

1 

5 

0.50 

Formula  Obtained  by  Diluting  Plain  Milk. 


Dil.  once  with  8-per-cent.  sugar  sol. 
Dil.  3  times  with  5-per-cent.  sugar  sol. 
Dil.  7  times  with  4-per-eent.  sugar  sol. 
Dil.  11  times  with  4-per-cent.  sugar  sol. 


Fat.    Sugar. Proteids. 

Per  Cent.  Per  Cent.  Per  Cent. 

XV.  1.80  6  2.00 

XVI.  0.90  5  1.00 

XVII.  0.45  4  0.50 

XVIII.  0.30  4  0.34 


154  INFANT-FEEDING. 

ing  a  bottle  of  Formula  2,  we  simply  add  1  ounce  of  milk 
for  the  third  month  to  Formula  2.  Frequently  the  ad- 
dition of  1  or  2  ounces  of  sterile  water  to  the  formula  will 
give  a  larger  bulk  and  satisfy  the  infant.  As  every  in- 
fant's appetite  and  gastric  capacity  is  different,  we  must 
carefully  note  the  condition  of  the  baby  after  its  feeding 
before  resorting  to  fixed  rules. 

Formula  for  Home  Use. 
At  4  Months.    Formula  3. — Take  of: — 

Fat 3.5         Cream   7  ounces. 

Sugar   6.5        Milk    1  ounce. 

Proteids 1.5         Lime-water    1  ounce. 

Lime-water.  .  .5.0        Water    25-32  ounces. 

Milk-sugar    6*4  drachms. 

Divide  into  eight  bottles;  heat  as  above  to  167°  F.; 
feed  every  three  hours. 

Formula  for  Home  Use. 

From  9  to  12  Months.    Formula  4. — Take  of: — 

Fat 4.0        Cream  8  ounces. 

Sugar   7.0        Milk    7%  ounces. 

Proteids 3.0        Lime-water    1  ounce. 

Lime-water. .  .5.0        Water    20-30  ounces. 

Milk-sugar    6%  drachms. 

The  above  to  be  divided  into  five  feedings,  heated  to 
167°  F.,  and  one  bottle  fed  every  four  hours. 

A  schedule  for  feeding  an  average  healthy  infant  from 
birth  upon  modified  cows'  milk,  showing  percentages  of 
fat,  sugar,  and  proteids,  and  the  daily  quantity  (Holt), 
is  given  on  page  153. 

Clinical  Illustrations  of  How  to  Feed  (from  the 
Author's  Private  Records). 

Case  I. — Baby  V.,  was  referred  to  me  for  treatment  April  3, 
1901. 

The  child  was  3  y2  months  old  at  time  of  commencing  treat- 
ment, and  weighed  8  pounds  and  10  ounces. 

History:    Breast-fed  about  two  weeks;  since  then  fed  on  milk 


CLINICAL  ILLUSTRATIONS  OF  FEEDING.  155 

diluted  with  water  and  milk-sugar;  food  was  steamed  forty  minutes. 
Child  had  always  been  constipated,  always  cries,  and  suffers  with 
colic. 

Gave  barley  and  condensed  milk  with  lime-water;  child  seemed 
to  do  well;  weight  was  about  10  pounds.  After  several  weeks  cream 
was  added  to  the  food.  After  this  addition  of  cream  the  child  vom- 
ited and  cried,  had  severe  colic,  was  restless  by  day,  and  had  in- 
somnia at  night.  Its  bowels  were  so  disturbed  that  all  milk  was 
stopped.  Barley-water  was  the  only  food  tolerated.  Then  cereal 
milk  was  prescribed.  The  cereal  milk  was  not  retained;  child  vom- 
ited after  each  feeding,  then  was  constipated,  which  alternated  with 
greenish,  dark  stools.  Infant  was  emaciated;  the  stools  contained 
mucus. 

Physical  Examination:  Very  emaciated  child;  temperature, 
100°  F.;  abdomen  distended,  very  flatulent;  skin  dry,  lost  elasticity; 
herpetic  eruption  on  lips  and  around  anus;  pulse,  140  and  feeble; 
throat  clean;  lungs  normal;  heart-sounds  very  feeble;  left  inguinal 
hernia. 

Diagnosis:     Athrepsia   resulting  from  chronic  gastric   catarrh. 

Food  Ordered: 

Pure  cows'  milk 2  ounces. 

Oatmeal -water    2  ounces. 

Granulated  sugar    yz  teaspoonful. 

Peptogenic  powder   y2  teaspoonful. 

Feed  every  three  hours.    Alternate  with: — 

Pure  cows'  milk, 

Barley-water   of  each  §ij. 

Granulated  sugar 3ss. 

Peptogenic  powder   y2  teaspoonful. 

Heat  this  mixture  slowly  for  ten  minutes,  then  boil  one  minute. 

Mother  reports  that  the  child  takes  food  well,  stools  are 
yellow,  and  child  passed  a  good  night,  but  still  has  eructations  and 
seems  colicky.  The  food  was  continued,  and  the  child  gained  ten 
ounces  in  seven  days. 

Weight,  April     3 8  pounds  and  10  ounces. 

Weight,  April    10 9  pounds  and  4  ounces. 

Weight,  April    17 9  pounds  and  8  ounces. 

Weight,  April    24 9  pounds  and  14  ounces. 

Weight,  May       1 10  pounds  and  4  ounces. 

Weight,  June      3 12  pounds  and  5  ounces. 

Weight,  June    15 13  pounds  and  12  ounces. 

Weight,  Dec.     20 19  pounds. 


156  INFANT-FEEDING. 

Extract  of  malt  was  ordered,  y2  teaspoonful  three  times  a  day. 
Every  week  the  formula  was  changed,  commencing  with: — 

Milk 2  ounces 

Barley-water  or  oatmeal-water.  .2  ounces 

One  week  later  I  ordered: — 
Milk 2%  ounces 


V  Formula  I. 


} 

Feed  every  three  hours. 


Barley-water  or  oatmeal-water.  .2%  ounces 


Raw  milk  3  ounces 

Barley-water  or  oatmeal-water.  .   3  ounces 

Peptogenic  powder 2  teaspoonfuls    ' 

Granulated  sugar yz  teaspoonful 

Feed  every  three  or  three  and  one-half  hours. 

I  ordered  this  infant  to  be  awakened  by  day  for  feeding,  but  not 
to  be  disturbed  at  night.  When  the  child  cried  after  feeding  when 
5  months  old,  instead  of  giving  Formula  III,  I  ordered:  — 

Raw  milk 4,yz  ounces  ~\ 

Barley-water    2%  ounces  I 

-o     .          •            j  ,,  r  Formula  IV. 

Peptogenic  powder    yz  measure  , 

Granulated  sugar yz  teaspoonful  J 

The  above  for  one  feeding.  Feed  every  three  or  three  and  one- 
hours.     Substitute  oatmeal-water  for  barley-water  every  other  day. 

Milk 5%  ounces  "j 

Barley-water    2       ounces 

Peptogenic  powder    yz  measure 

Granulated  sugar yz  teaspoonful  J 

Alternate  with  oatmeal-water.  Feed  every  three  and  one-half 
or  four  hours. 


>  Formula  V. 


Case  II. — Dorothy  L.  F.,  11  months  old,  was  referred  to  me  for 
treatment  on  March  18,  1901,  by  Dr.  H.  J. 

The  history  elicited  was :  The  baby  is  still  nursing  and  appears 
undersized,  very  anaemic,  and  poorly  developed.  No  evidence  of 
teething;  cannot  walk  nor  talk.  Has  had  summer  complaint.  Re- 
cently suffered  with  constipation.  Had  diarrhceal  stools  some  time 
ago;  stools  were  greenish  in  color,  and  contained  curds  and  mucus. 
Has  had  a  cough  lasting  three  weeks;  also  sniffles.  A  restless 
sleeper,  rarely  sleeping  more  than  one-half  hour  at  a  time  during 
the  day.  Is  frequently  very  raw  between  thighs  and  on  buttocks. 
Child  is  very  flatulent. 


CLINICAL  ILLUSTRATIONS  OF  FEEDING.  157 

Physical  Examination:  A  very  frail  child;  large  abdomen; 
slight  evidence  of  rickets;  very  feeble  heart-action;  lungs  normal; 
spleen  palpable;  liver  very  much  enlarged;  colon  distended,  tym- 
panitic on  percussion;  muscles  of  extremities  very  flabby;  bones 
very  small;  epiphyses  of  long  bones  very  much  enlarged;  tongue 
coated;  throat  normal;  some  adenoids. 

Specimen  of  breast-milk  sent  to  chemist  for  examination 
showed: — 

Quantity,  about  2  ounces,  or  60  cubic  centimetres. 
Reaction  slightly  alkaline. 

Specific  gravity 1.03105 

Fat   1.22 

Sugar  7.07 

Proteids  0.98 

Shows  low  fat  and  low  proteids. 

The  baby  weighed  about  4  y2  pounds  at  birth,  and  weighed  be- 
tween 12  and  13  pounds  when  6  months  old.  It  now  weighs  naked 
about  16  pounds. 

From  the  history  I  learned  that  the  mother  menstruated  while 
nursing  since  her  child  was  4  months  old.  The  infant's  restlessness 
was  evidently  associated  with  this  condition. 

The  study  of  the  chemical  examination  of  the  breast-milk 
which  this  child  received  easily-  explains  the  poor  development,  the 
proteids -being  less  than  1  per  cent.,  besides  a  very  low  percentage 
of  fat  being  also  partly  responsible. 

Treatment:    Absolute  weaning  from  the  mother's  breast. 

Pure  cows'  milk,  warmed  to  feeding  temperature,  or  about  100° 
F.,  6  ounces  to  be  given  at  each  feeding.  Feed  every  four  hours; 
strict  observance  of  interval  of  feeding  and  careful  attention  to 
sterility  of  everything  coming  in  contact  with  food  or  utensils  to 
be  used. 

Medication:  One-half  teaspoonful  of  malt-extract  given  three 
times  a  day. 

This  food  was  not  well  assimilated,  so  I  ordered  y2  measure  of 
peptogenic  milk-powder  to  be  added  to  each  6  ounces  of  raw  milk. 
Gradually  heat  in  a  saucepan  over  a  small  flame  for  five  minutes, 
then  heat  more  rapidly  and  boil  for  about  ten  seconds.  Repeat 
every  four  hours.  Prepare  each  bottle  separately.  Do  not  use  the 
food  a  second  time,  if  the  bottle  is  not  emptied  at  one  feeding. 

My  record  three  days  later  shows:  Had  a  very  good  night. 
Better  appetite,  formerly  took  only  3  to  4  ounces,  now  takes  almost 
5  ounces.    Did  not  moan  last  night. 

March  27th:    Child  looks  better;  bowels  move  twice  naturally, 


158  INFANT-FEEDING. 

and  have  a  yellowish  color,  but  no  curds.  Temperature,  99°  F.; 
pulse,  120;  respiration,  36. 

This  feeding  was  continued  for  about  three  weeks,  and  owing 
to  good  results  no  changes  were  made. 

This  is  the  mother's  report,  which  I  copy: — ■ 

April  8th:  Had  a  good  night;  slept  from  10.30  p.m.  to  6.30  A.M. 
continuously.  Bowels  are  splendid,  yellow;  three  stools  yesterday. 
Has  a  slight  irritation  of  genitals;  seems  to  be  fumbling  with  the 
parts.  Examination  showed  vulvitis,  irritation  due  to  scratching, 
slight  eczematous  intertrigo. 

Diet  Ordered:  To  continue  raw  milk  modified  with  peptogenic 
powder;  in  addition  thereto  beef -soup  thickened  with  either  hominy, 
sago,  or  farina.  Feed  two  hours  after  milk-bottle  once  a  day,  pref- 
erably about  noon.  Give  the  child  the  white  of  a  raw  egg  with 
sweetened  water  every  other  day.  The  child  received  soup,  alter- 
nating the  next  day  with  the  white  of  egg,  in  the  following 
manner: — ■ 

Warm  raw  milk,  modified  with  pep- 
togenic      6  ounces  at    6  a.m. 

Milk,  peptogenic   6  ounces  at  10  a.m. 

Soup,  thickened 6  ounces  at  12  Noon. 

Milk,  peptogenic   6  ounces  at    2  p.m. 

Milk,  peptogenic   6  ounces  at     6  p.m. 

This  food  was  well  borne ;  the  child  gained.  To  improve  the  ap- 
petite 1  minim  of  nux  vomica  was  ordered  three  times  a  day,  before 
three  feedings. 

Warm  or  raw  milk,  modified  by  heating  with  peptogenic  as  di- 
rected above:  — 

6  ounces 6  a.m. 

6  ounces 10  a.m. 

White  of  raw  egg,  sweetened 12  Noon. 

Milk  with  peptogenic 2  p.m. 

Milk  with  peptogenic 6  p.m. 

Malt-extract  was  discontinued  every  other  week  and  an  emul- 
sion of  codliver-oil  ordered;  25  per  cent,  of  oil  was  given.  Each 
teaspoonful  of  the  emulsion  contained  2  grains  each  of  glycerophos- 
phate of  lime  and  glycerophosphate  of  soda. 

May  14th:  We  discontinued  giving  peptogenic  and  simply  gave 
the  baby  raw  milk  warmed  immediately  before  feeding.  The  milk 
was  thickened  by  giving  zwieback  and  bread-crumbs.  I  also  ordered 
steak-juice,  fed  several  teaspoonfuls  at  noon  with  some  bread- 
crumbs  or   cracker-dust,   and  roast-beef  juice.     Also   ordered   egg- 


CLINICAL  ILLUSTRATIONS  OF  FEEDING.  159 

crackers,  bread  and  butter,  and  soup  made  with  mashed  peas  in 
which  meat  was  boiled. 

June  1st:  Somatose  1/2  teaspoonful  to  be  stirred  with  milk  or 
soup;  repeat  the  dose  three  times  a  day.  Also  ordered  raw  apple- 
pulp  sweetened  with  sugar. 

June  20th:  Discontinued  raw  white  of  egg,  and  gave  half  of 
soft-boiled  egg,  half  of  yolk  and  half  of  white,  followed  by  bottle 
of  milk  at  10  a.m. 

Child  now  weighs  19  1/2  pounds. 

Treatment  discontinued;  child  went  to  the  sea-shore.  I  did  not 
see  the  child  until  middle  of  September,  three  months  later.  Has 
had  summer  complaint;  food  changed;  different  milk  used  in 
country  evidently  the  cause.  Child  now  weighs  18  1/2  pounds.  This 
child  did  not  receive  one  drop  of  milk  all  summer,  simply  put  on 
pea-soup,  cocoa  and  zwieback,  and  Nestle's  food.    I  ordered: — 

Farina  boiled  in  milk. 

Rice  boiled  in  milk. 

Use  one-half  milk  and  one-half  water. 

Boil  one  hour  or  longer. 

Also  some  barley-soup,  afternoon  cocoa,  or  milk,  in  the  follow- 
ing manner:  — 

Milk   4  ounces. 

Water    4  ounces. 

Granulated  sugar  ...  1  teaspoonful. 

_  Lime-water 1  teaspoonful. 


Feed  at  6  a.m. 


Feed  at  10  a.m.,  same  as  above. 

Feed  at  12  noon,  soup  made  from  chicken  or  beef  thickened 
with  barley. 

Milk   6  ounces. 

Chocolate  or 

Feed  at  2.30  p.m.    -j   Cocoa   2  teaspoonfuls. 

Granulated  sugar  ...  2  teaspoonfuls. 

.  Water    2  ounces. 

Avoid  all  lumps  in  chocolate  by  rubbing  up  with  hot  water 
and  gradually  adding  the  milk.  Heat  over  small  flame  and  stir 
well. 

Feed  at  6.30  p.m.,  milk  thickened  with  egg-cracker  or  zwieback. 

This  food  was  well  assimilated,  and  then  the  following  was 
added:  Sliced  apple,  in  the  morning;  pudding  made  from  broken 
zwieback,  some  milk,  and  yolk  of  egg. 


160  INFANT-FEEDING. 

September  30th:  Shredded  wheat,  oatmeal,  or  farina  with  milk 
was  allowed  in  addition  to  the  afternoon  cocoa  or  chocolate  feeding 
above  ordered.  At  noon  chicken  bouillon  or  soup,  to  which  yolk  of 
raw  egg,  well  beaten,  was  allowed. 

In  October  we  gave  raw  scraped  steak  on  a  soda-biscuit.  Also 
ordered  fresh  vegetables,  stewed  or  mashed  peas,  some  spinach  and 
cauliflower,  and  baked  potato  with  butter. 

Bone-marrow,   1   teaspoonful  three  times   a  day,  was   ordered. 

The  child  made  excellent  progress.  Teeth  appeared,  and  the 
child  is  strong,  well,  and  able  to  walk;  no  physical  defect  is  visible; 
mentally  the  child  is  normal,  and,  indeed,  to  all  appearances  it  is 
now  a  normal  child. 

Case  III.  Dyspeptic  Infant,  Requiring  Careful  Bottle-feeding, 
now  Perfectly  Well.- — Baby  Douglas  C.  M.,  child  of  a  physician,  was 
born  May  29,  1901.  Weighed  at  birth  9  pounds.  Was  breast-fed 
about  two  months.  Owing  to  swollen  breasts,  the  milk  suddenly 
ceased.  The  child  was  weaned.  Weight,  12  pounds.  Stools  normal 
at  time  of  weaning.  Hand-feeding  with  equal  parts  of  milk  and 
water  was  tried.  As  this  was  not  well  borne,  Mellin's  food  was 
given. 

When  first  seen  by  me  the  infant  had  frequent  attacks  of  vomit- 
ing; greenish  stools,  containing  curds  and  mucus.  Cries  with 
colicky  pains.     Has  constant  intestinal  fermentation. 

Infant  at  4  months,  while  suffering  with  colic,  was  given: — 

Pure  milk    14  ounces.             -\ 

Barley-water  20  ounces.               I 

Granulated  sugar  . .  4  teaspoonfuls.    C 

Lime-water    7  teaspoonfuls.  J 

Mix  the  above  and  divide  into  seven  clean  bottles.  Place  in  a 
refrigerator  until  required.  At  feeding-time  empty  contents  of  a 
bottle  into  a  saucepan  and  allow  the  food  to  come  to  a  boil,  then 
immediately  remove  from  heat.  When  cooled  to  feeding  tempera- 
ture, give  it  to  the  baby.  Usual  temperature  is  about  100°  F.,  or 
blood-heat. 

In  addition  to  the  above  food  prune-water,  made  in  the  follow- 
ing manner,  was  ordered  for  thirst:  — 

Fleshy  prunes 1  dozen. 

Granulated  sugar   3  teaspoonfuls. 

Water  2  teacupfuls. 

Mix  together  and  boil  for  thirty  minutes.  Strain;  feed  when 
cold.    Three  to  6  teaspoonfuls  can  be  given  at  one  time. 


CLINICAL  ILLUSTRATIONS  OF  FEEDING.  1G1 

Fresh  orange-juice,  3  teaspoonfuls  one  hour  before  milk-feeding, 
once  a  day. 

When  seen  a  few  days  later  it  was  found  that  the  child  had 
had,  during  the  day,  five  greenish-yellow  stools,  containing  cheesy 
curds. 

Ordered  oleum  ricini,  1  teaspoonful  at  10  a.m. 

Feed  at H-30  a.m. 

Feed  at 2.30  p.m. 

Feed  at 5.30  P.M. 

Feed  at 8-30  p.m. 

If   looseness    continues,   leave    out    sugar   and    substitute    sac- 
charin, 1/2  grain  to  each  bottle. 
Following  day  ordered:  — 

Milk 20  ounces.  -\ 

Barley-water   14  ounces.  I 

~  .   ,  ,  ,       >  Formula  II. 

Sugar 4  teaspoonfuls.    | 

Lime-water    7  teaspoonfuls.  J 

Mix  the  above  and  divide  into  seven  bottles.  Scald  each  bottle 
before  feeding. 

Barley-water  is  made  by  adding  a  tablespoonful  of  barley  to  a 
pint  of  water,  boiling  for  five  minutes,  straining  through  cheese- 
cloth, and  again  adding  enough  water  to  make  a  pint. 

Infant  cried  and  still  seemed  hungry  after  feeding,  and  the  food 
was  increased: — 

Whole  milk  14  ounces.  -\ 

Gravity  cream    ...  7  ounces.  I  ^^  m 

Sterile  water 20  ounces. 

Cane-sugar 5  teaspoonfuls.  J 

Mix  the  raw  milk  and  cream  in  a  clean  bottle  and  add  the 
water  and  sugar.  Divide  into  seven  bottles  and  keep  in  a  refrig- 
erator until  feeding-time.  Keep  bottles  well  stoppered  with  ab- 
sorbent cotton.  Warm  the  bottles  in  hot  water  at  feeding-time. 
Feed  every  three  hours. 

The  following  day  the  child  had  no  stool  from  2  A.M.  to  10  A.M. 
It  seems  better  satisfied  after  the  bottle,  and  takes  food  greedily. 

Food  changed  to:  — 

Whole  milk   20  ounces.  -v 

Barley-water  14  ounces.  I  &  ^ 

Sugar    4  ounces.  | 

Lime-water    7  teaspoonfuls.  J 

Divide  into  seven  feedings.    Feed  every  three  hours. 

li 


162  INFANT-FEEDING. 

As  the  above  formula  agreed,  I  ordered:  — 

Whole  milk 21  ounces.  -j 

Barley-water  14  ounces.  I  Formula  V. 

Sugar    4  teaspoonfuls.   J 

Scald  the  milk  and  divide  into  seven  feedings.  Feed  every  two 
and  three-fourths  or  three  hours. 

Gained  one  pound  during  the  week;  has  yellowish  stools  after 
each  feeding;  no  vomiting;  cries  after  feeding;  appears  dissatisfied. 

Changed  feeding  to: — 

Whole  milk   20       ounces.  ^ 

Barley-water   12       ounces.  >  Formula  VI. 

Saccharin   3%  grains.  J 

Divide  into  seven  feedings.  Scald  the  raw  milk  with  hot  barley- 
water;  then  put  in  ice-chest  until  feeding-time.  Boil  two  minutes  in 
saucepan  before  feeding. 

Stool  after  each  feeding,  yellow,  normal  consistency,  alkaline 
reaction.  Child  does  not  sleep  well;  seems  hungry.  Food  changed 
to:  — 

Whole  milk  36       ounces.  -j 

Barley-jelly    12       ounces.  >  Formula  VII. 

Saccharin   3  y2  grains.  J 

Add  1  teaspoonful  of  cream  to  each  feeding;  discontinue  if 
vomiting  or  if  cheesy  curds  appear  in  stools.  Scald  milk  as  before. 
Feed  every  three  hours. 

To  make  barley-jelly  take  2  heaping  tablespoonfuls  of  barley  to 
12  ounces  of  water,  boil  down,  and  again  add  enough  water  to  make 
12  ounces. 

Child  still  appears  hungry  after  feeding.  Stools  less  frequent. 
No  vomiting.  Has  small,  rose-colored  spots  on  legs  and  face. 
Weight,  13  pounds. 

Feeding  changed  to:  — 

Milk 42  ounces.  •)   _,  ,     TTTTT 

I  Formula  VIII. 
Cream    2  ounces.  j 

Divide  into  seven  bottles  and  feed  every  three  hours. 

If  food  does  not  agree  add  1  teaspoonful  of  Fairchild's  pepto- 
genic  milk-powder  to  each  bottle  and  heat  for  three  minutes  before 
feeding. 

Ordered  two  doses  of  calomel;  1/10  grain  given. 


CLINICAL  ILLUSTRATIONS  OF  FEEDING.  163 

Child  appears  very  bright.  Has  yellowish  stools,  no  colic;  ab- 
domen not  distended.  No  evidence  of  vomiting.  Sleeps  well  all 
night. 

Feeding  changed  to: — 

Milk     48  ounces.  -) 

Cream   4  ounces.  I  Formula  IX. 

Dextrinized  wheat.  .     7  teaspoonfuls.   J 

Sweeten  and  heat  as  before.     Divide  into  seven  bottles. 

To  make  dextrinized  wheat  take  3  pounds  of  plain  wheat-flour, 
boil  in  a  bag  for  five  hours,  then  dry  in  the  oven,  break  open,  reject 
the  rind,  and  grate  into  powder. 

Child  did  not  digest  the  dextrinized-wheat  feeding.  Changed  to 
pure  milk.    Child  now  takes  pure  milk,  5  to  6  ounces. 

To  relieve  eczematous  excoriation  on  buttocks,  ordered:  — 

3  Calamin 3.0 

Zinc  oxide  alb 3.0 

Lanolin    30.0 

Apply  t.  i.  d. 

Child  does  not  sleep  well  at  night.  Ordered  milk  steamed  in 
double  boiler  for  twenty-five  minutes.  Child  cried  very  much  during 
the  last  few  days;  had  thin,  yellowish  stools  after  each  bottle. 

To  relieve  thin,  watery  stools  ordered: — - 

U  Acid.  HC1.  dilut 2.0 

Essence  of  pepsin   60.0 

Sig. :    Teaspoonful  three  times  a  day  before  feeding. 

Owing  to  an  eczema  on  the  buttocks  after  applying  the  salve, 
ordered  equal  parts  of  pulverized  zinc  oxide  and  talcum  dusted  over 
salve  on  buttocks. 

For  the  loose  bowels  ordered  the  rectum  and  colon  irrigated 
with  y2  pint  of  chamomile-tea  to  which  was  added  10  grains  of 
tannic  acid.     Temperature  of  irrigation,  about  105°  F. 

Oleum  ricini,  1  teaspoonful,  internally. 

Changed  feeding  to:  — 

Milk    4       ounces.  \ 

Barley-water  .   iy2  ounces.  I  Formula  X. 

Arrowroot  ...    1  heaped  teaspoonful.    J 

Boil,  and  feed  every  three  or  three  and  one-half  hours,  alter- 
nating with  thickened  rice-soup  or  rice-water,  4  to  6  ounces  at  one 
feeding.    Baby  did  very  well  on  this  diet,  assimilated  the  food,  and 


164  INFANT-FEEDING. 

gained  in  weight.  Had  one  or  two  yellowish,  well-digested  stools 
daily.  After  this  improvement  I  ordered  soups  and  white  of  egg. 
The  child  weighed,  at  6  months,  18  pounds.  The  child  is  per- 
fectly well,  walks  and  talks,  and  is  now  in  his  second  year,  with 
normal  dentition. 


Effect  of  Heating  Milk. 

Pasteurizing  and  sterilizing  are  still  necessary  evils. 
They  are  really  more  useful  in  keeping  milk  from  spoil- 
ing than  for  any  other  purpose.  The  diseases  transmitted 
by  milk  are  very  few,  and  are  almost  invariably  due  to 
contaminated  water  and  utensils,  and  should  be  obviated 
by  dairy  inspection.  Bacterial  growth  is  what  is  to  be 
feared  in  the  milk,  and  this  can  be  prevented  by  keeping 
the  milk  at  low  temperatures.  If  the  infant's  food  or  milk 
cannot  be  kept  below  50°  F.,  it  should  be  pasteurized  or 
sterilized  as  soon  as  possible,  as,  while  the  bacteria  are 
killed  by  heat,  the  toxins  they  produce  are  not  destroyed. 

Heating  produces  many  changes  in  milk,  some  of 
which  are  not  thoroughly  understood.  Boiled  milk  does 
not  curdle  with  rennet  as  easily  as  raw  milk,  the  cream  is 
about  one-third  denser  than  the  cream  of  raw  milk,  and 
the  albumin  is  rendered  insoluble. 

The  following  table  of  C.  H.  Stewart  shows  the  per- 
centage of  soluble  albumin  in  milk  at  various  tempera- 
tures : — 


Time  of  Heating. 

10  minutes  at  60°  C.  (140°  F.) 
30  minutes  at  60°  C.  ( 140°  F. ) 
10  minutes  at  65°  C.  (149°  F.) 
30  minutes  at  65°  C.  ( 149°  F. ) 
10  minutes  at  70°  C.  (158°  F. ) 
30  minutes  at  70°  C.  (158°  F. ) 
10  minutes  at  75°  C.  (167°  F. ) 
30  minutes  at  75°  C.  (167°  F.) 
10  minutes  at  80°  C.  ( 176°  F. ) 
30  minutes  at  80°  C.  (176°  F.) 


Soluble  Albumin, 

Soluble  Albumin 

in  Fresh  Milk. 

in  Heated  Milk. 

Per  Cent. 

Per  Cent. 

0.423 

0.418 

0.435 

0.427 

0.395 

0.362 

0.395 

0.333 

0.422 

0.269 

0.421 

0.253 

0.380 

0.070 

0.380 

0.050 

0.375 

none 

0.375 

none 

changes  in  milk  caused  by  sterilization.       1g5 

Changes  in  Milk  Caused  by  Sterilization. 

In  some  late  experiments  made  by  Dr.  E.  M.  Hies- 
land  and  published  by  Dr.  B.  C.  Hirst45  Dr.  Hiesland 
found  that  by  sterilization:  1.  The  albumin  is  coagu- 
lated. 2.  Casein  is  less  readily  precipitated  by  rennet  than 
in  normal  milk.  Acid  corrects  this  condition.  3.  Fat  is 
freed  to  a  slight  extent;  fat  not  freed  has  a  lessened 
tendency  to  coalesce.  4.  Sugar  undergoes  some  change, 
as  shown  by  its  lessened  dextrorotatory  power. 

The  considerations  suggested  by  a  knowledge  of  the 
foregoing  facts  are: — 

1.  The  coagulation  of  milk-albumin  by  sterilization 
may  render  the  milk  more  difficult  of  digestion.  2. 
Sterilization  interferes  with  the  coagulability  of  milk  by 
rennet,  and  presumably,  therefore,  with  its  digestibility 
by  the  gastric  juice.  3.  Free  fat,  as  found  in  sterilized 
milk,  is  probably  not  readily  assimilated  in  infant-food. 
The  fat  not  free,  being  inclosed  in  a  less  easily  destructible 
envelope,  is  probably  slow  of  digestion.46 

On  the  question  of  sterilized  milk  the  weight  of  evi- 
dence seems  to  show  that  the  process,  while  preventing 
undue  fermentation,  so  changes  certain  of  the  natural 
ferments  and  some  of  the  fats  that  the  milk  is  less  easily 
digested  and  less  nutritious.47 

At  the  New  York  Medical  Association's  Meeting, 
March  16,  1891,  Brush  read  a  paper  on  "Sterilized  Milk," 
in  which  he  objected  to  the  sterilization  of  milk  for  in- 
fants' food  because  the  process  devitalized  it.  Among  the 
other  ways  in  which  the  value  of  the  milk  was  lessened 
by  sterilization,  he  said,  was  that  the  soluble  albumin  was 
made  insoluble.  He  believed  that  a  child  raised  on  steril- 
ized milk  would  be  less  robust,  and  have  a  constitution 


45  Medical  News,  January  31,  1891. 
40  Medical  Record,  February  28,  1891. 

47  North  American  Practitioner,  June,  1892,  from  the  "Year-book 
of  Treatment"  (Lee  Brothers  &  Company). 


1GG 


INFANT-EEEDING. 


that  would  more  readily  succumb  to  deleterious  influences 
than  one  fed  on  natural  milk.  He  contended  that  every 
human  being  required  some  living  food,  and  that  the 
cause  of  every  scurvy  was  deprivation  of  such  living  food. 
The  sterilization  of  milk  for  adults  was  of  but  little  con- 
sequence, as  they  had  other  kinds  of  food;  but  it  became 
a  matter  of  the  highest  importance  to  an  infant  whose 
only  food  was  milk.48 

Mateena  Home  Modifies. 

This  is  a  glass  apparatus  for  the  modification  of  cows' 
milk  at  home,  and  consists  of  a  glass  vessel  with  pouring- 


Fie:.  22. 


lip,  shaped  like  a  graduate,  holding  sixteen  ounces.  The 
outer  surface  is  divided  by  vertical  lines  into  seven  panels ; 
one  panel  shows  the  ordinary  ounce  graduation;  the  six 
others  show  six  different  formulae,  so  arranged  as  to  be 
suitable  for  the  entire  first  year's  feeding.     The  accom- 


48  Boston  Medical  and  Surgical  Journal,  April  9,  1891. 


MATERNA  HOME  MODIFIER. 


167 


panying  diagram  is  a  more  or  less  accurate  reproduction 
of  the  arrangement  of  these  panels. 

It  is  possible  to  obtain  other  percentages  than  those 
shown  on  the  panels,  by  mixing  what  is  called  for  by  two 
adjacent  formulae;  as,  for  instance,  equal  quantities  made 
according  to  Formulas  1  and  2  combined  will  give:  fat, 
2  1/4  per  cent.;   proteids,  0.7  per  cent.;   sugar,  6  per  cent. 


1. 

3d-14th  Day. 

Fat,  2  56. 

Proteids,  0.6  56 . 

Sugar,  6$. 

2. 

2d-6th  week. 

Fat,  l^if. 

Proteids,  0.8  56. 

Sugar,  6ji. 

3. 

6th-llth  week. 

Fat,  3  f, . 

Proteids,  1  <fa . 

Sugar,  6$. 

4. 

11  wk.-5  mo. 
Fat,  Z'A  f, . 

Proteids,  1J£  ft. 
Sugar,  7  ?» . 

5. 

5th-9th  mo. 

Fat,  if>. 

Proteids,  256 . 

Sugar,  7f. 

6. 

9th-12th  mo. 

Fat,  3^  f, . 

Proteids,  2J£  f  . 

Sugar,  33-£  ^ . 

Milk 

Milk 

Milk 

Milk 

Milk 

Milk 

Cream 

Cream 

Cream 

Cream 

Cream 

Lime-water 

Lime-water 

Lime-water 

Water 

Water 

Water 

Lime-water 

Milk-sugar 

Lime-water 

Milk-sugar 

Water 

Water 

Cream 

Milk-sugar 

Milk-sugar 

Barley-gruel 

Milk-sugar 

Gr.  sugar 

1 

I                     A 

As  may  readily  be  seen,  all  the  formulas  call  for  the 
same  ingredients,  excepting  the  sixth,  which,  instead  of 
water,  requires  barley-gruel,  and  granulated  sugar  in  place 
of  milk-sugar. 

The  method  of  using  the  apparatus  is  extremely 
simple.  Having  decided  upon  the  formula  to  be  used, 
that  panel  is  to  be  observed  to  the  exclusion  of  all  the 
others.     The  respective  ingredients  are  then  poured  into 


1GS  INFANT-FEEDING. 

the  vessel,  to  tlie  line  below  the  designated  substance. 
Thus,  milk-sugar  is  put  in  first  (or,  in  its  absence,  gran- 
ulated; and  the  line  with  the  cross  shows  to  what  point 
the  latter  should  be  used),  then  the  water,  lime-water, 
cream,  and  milk  in  the  order  shown.  The  whole  is  then 
stirred,  and  the  result  will  be  a  milk  whose  formula  is  at 
the  top  of  the  panel.  The  milk  used  with  the  apparatus 
should  be  good  average  milk.  The  cream  should  be  the 
light  centrifugal  cream  as  obtained  in  bottled  milk  (16-20 
per  cent.).  The  water  should  be  hot,  to  dissolve  the  sugar. 
The  barley-gruel  should  be  prepared  in  the  usual  way  with 
Robinson's  or  ordinary  barley. 

According  to  the  age  and  size  of  the  child,  the  vessel 
must  be  filled  once,  twice,  or  three  times  to  obtain  the 
quantity  requisite  for  the  twenty-four  hours'  feeding. 
The  pouring  into  bottles  and  sterilization  are  then  done 
as  usual.  Full  directions,  including  a  schedule  for  the 
twenty-four  hours'  feeding  at  the  various  periods  of  the 
child's  growth,  accompany  the  apparatus,  which  is  sim- 
ple, accurate,  and  economical,  making  properly  modified 
milk  of  practical  value  obtainable  in  places  where  it  has 
hitherto  been  impossible  to  get  it. 

The  materna  is  adapted  for  home  use  only  when  the 
physician  notes  results.  To  intrust  an  apparatus  of  this 
kind  into  the  hands  of  a  mother  or  nurse  not  conversant 
with  the  difference  in  the  percentage  of  fat  contained  in 
cream  is  not  only  wrong,  but  will  prove  disastrous  to  the 
infant  so  fed  before  many  weeks  are  over.  The  author 
recently  saw  a  case  of  dyspepsia  brought  about  by  feeding 
in  this  careless  manner.  On  the  other  hand,  the  appa- 
ratus will  serve  as  a  guide  to  those  physicians  whose  train- 
ing in  percentage-feeding  requires  occasional  assistance. 

A  very  practical  "milk-modifying  gauge"  devised  by 
Mitchell  has  been  placed  on  the  market.  It  can  be  pro- 
cured from  the  National  Drug  Company  of  Philadelphia. 
It  is  designed  to  aid  those  unfamiliar  with  home  modi- 
fication, and  is  especially  valuable  to  those  distant  from 
large  cities  with  laboratories. 


CHAPTER  XXIV. 

Sterilized  Milk. 

E.  G.  Freeman,  M.D.,  in  a  paper  read  before  the 
Academy  of  Medicine,  New  York,  May  11,  1893,  says, 
of  sterilization,  that,  when  milk  is  sterilized  at  212°  F. 
(100°  C),  absolute  sterilization  is  not  obtained,  but  the 
milk  is  rendered  less  digestible  than  it  is  in  the  raw  state, 
and  physicians  who  have  used  sterilized  milk  as  a  regular 
food  find  that  often  infants  so  fed  do  not  thrive.  This 
clinical  experience,  chemists  state,  is  occasioned  by  the 
many  modifications  produced  in  milk  by  this  tempera- 
ture of  212°  F.,  the  starch-liquefying  ferments  being 
destroyed,  the  casein  being  rendered  less  coagulable  by 
rennet  and  therefore  being  acted  upon  slowly  and  im- 
perfectly by  pepsin  and  pancreatin,  and  the  milk-sugar 
being  destroyed;  these  chemical  changes  begin  to  be 
marked  when  a  temperature  of  176°  F.  (80°  C.)  is 
reached,  and  become  more  marked  as  the  temperature 
becomes  higher. 

In  the  Medical  Age,  September  25,  1893,  it  is  stated 
that  Dr.  Fayel,  of  Caen,  France,  says  boiled  milk  is  more 
or  less  indigestible,  and  is  in  no  respect  safer  than  un- 
boiled milk;  the  temperature  at  which  milk  boils  is  in- 
sufficient to  destroy  microbes,  and  the  milk  is  therefore 
not  sterilized,  while  its  density  is  increased  by  the  boiling 
above  that  which  is  suitable  for  infant-digestion. 

In  the  Therapeutic  Gazette,  October  16,  1893,  is  a 
translation  from  a  communication  to  the  Societe  de  Mede- 
cine  de  Lyon,  by  Crolas.  Crolas  concludes  that  boiling 
milk  relieves  the  milk  of  small  quantities  of  butter,  but 
has  no  action  whatever  upon  the  casein  or  lactose;  that 
the  boiling  increases  the  quantity  of  soluble  phosphates. 

(169) 


170  INFANT-FEEDING. 

lie  therefore  believes  that  boiled  milk  as  an  article  of 
food  is  equivalent,  if  not  superior,  to  unboiled  milk. 

At  the  meeting  of  the  New  York  Academy  of  Medi- 
cine, Section  in  Pediatrics,  May  12,  1892,  Dr.  A.  Jacobi, 
in  the  discussion  upon  infant-foods,  made  the  following 
points: — 

It  was  a  great  error  to  suppose  that  sterilized  milk 
was  anything  like  human  milk;  it  required  just  as  much 
modification  as  though  it  were  not  sterilized. 

Alkalinity  in  cows'  milk  was  always  suspicious,  for 
it  was  evidence  that  it  had  been  "doctored."  The  most 
dangerous  alkali  was  bicarbonate  of  soda,  for  in  milk  thus 
treated  the  ptomaine-producing  germs  develop  best. 

While  pepsin  was  sometimes  useful,  he  objected  to  its 
indiscriminate  use;   without  an  acid  it  was  inert. 

Sugar  was  required  in  an  artificial  food,  but  he  did 
not  believe  that  milk-sugar  was  best.  There  was  a  close 
relationship  between  milk-sugar  and  lactic  acid.  The 
change  from  one  to  the  other  was  very  rapid.  Some 
lactic  acid  was  necessary  for  proper  digestion,  but  an 
o^erquantity  produced  hyperacidity  and  indigestion.49 

Excerpt  from  an  address  at  the  Eleventh  Inter- 
national Congress,  Eome,  Italy,  April  4,  1894,  by  A. 
Jacobi,  M.D.: — 

"I  shall  only  dwell  upon  two  articles  which  have 
taken  an  improper  hold  on  the  imagination  of  medical 
men  and  have  almost  been  raised  into  subjects  of  super- 
stitious veneration.  The  use  of  milk-sugar  in  the  place 
of  cane-sugar  in  children's  food  to  any  extent  beyond 
what  there  is  in  cows'  milk,  or  its  exclusive  employment, 
is  a  source  of  acid  gastric  catarrh  which  afterward  re- 
quires medicinal  correction;  it  is  transformed  into  lactic 
acid  beyond  need  and  proves  a  detriment,  to  the  full 
conviction  of  all  those  who  will  give  the  subject  proper 
attention.     Thoughtful  experience  is  as  valuable  an  ob- 


'  Virginia  Medical  Monthly,  June,  1892. 


CHANGES   IN   MILK  CAUSED  BY  BOILING.  171 

jective  addition  to  our  knowledge  as  a  mere  chemical  or 
theological  theory. 

"Next  in  order  is  sterilized  milk,  on  which  hundreds 
of  thousands  of  babies  are  now  being  fed  to  the  exclusion 
of  everything  else.  JSTobody  would  teach  nowadays  the 
feeding  on  unchanged  or  unmixed  cows'  milk  to  babies 
as  a  proper  course  to  take, — as  a  substitute  for  mothers' 
milk.  But  sterilized  milk  has  been  looked  up  to  as  an  ob- 
ject of  faith  and  treated  as  a  pope  among  foods,  infallible. 
To  feed  babies  exclusively  on  sterilized  milk  has  become 
the  rage  since  it  was  recommended  by  gentlemen  of  the 
highest  possible  standing  in  science,  but,  as  far  as  I  know, 
little  conversant  with  the  art  of  treating  well  and  sick 
infants.  I  speak  so  bluntly  because  I  love  babies,  one  and 
all. 

"Sterilized  milk  —  pasteurized  is  inferior  to  it  —  is 
superior  to  unchanged  cows'  milk,  still  not  human.  Of 
7  cases  observed  this  winter  of  infantile  scurvy, — -a  nutri- 
tive disorder  as  far  as  we  can  make  out, — there  were 
3  that  had  been  fed,  2  exclusively,  1  for  several  months, 
on  sterilized  cows'  milk."  50 

The  Chemical  and  Physiological  Changes  in 
Milk  Caused  by  Boiling.51 

Milk  consists  of  a  multitude  of  cells  suspended  in 
serum.  The  cells  are  fat-cells,  which  form  the  cream; 
the  remaining  cells  are  nucleated,  and  of  the  nature  of 
white  blood-corpuscles.  The  serum  consists  of  water,  in 
which  is  dissolved  milk-sugar  and  serum-albumin,  with 
various  salts,  and,  chief  of  all,  casein.  The  cells,  with 
the  exception  of  the  fat-corpuscles,  are  all  living  cells, 
and  they  retain  their  vitality  for  a  considerable  time  after 
the  milk  is  drawn  from  the  mammary  gland. 

60  Medical  Eecord,  May  19,  1S94. 

51  J.  L.  Kerr,  M.D.,  CM.,  F.R.S.E.,  in  the  British  Medical  Jour- 
nal, December,  1895. 


172  INFANT-FEEDING. 

There  is  reason  for  supposing  that,  when  fresh  milk 
is  ingested,  the  living  cells  are  at  once  absorbed  without 
any  process  of  digestion,  and  enter  the  blood-stream  and 
are  utilized  in  building  up  the  tissues.  The  casein  of  the 
milk  is  digested  in  the  usual  way  of  other  albuminoids,  by 
the  gastric  juice,  and  absorbed  as  peptone.  There  is  also 
absorption  of  serum-albumin  by  osmosis.  The  chemical 
result  of  boiling  milk  is  to  hill  all  the  living  cells  and  to 
coagulate  all  the  albuminoid  constituents.  Milk  after 
boiling  is  thicker  than  it  was  before. 

The  physiological  results  are  that  all  the  constituents 
of  the  milk  must  be  digested  before  it  can  be  absorbed 
into  the  system;  therefore  there  is  distinct  loss  of  utility 
in  the  milk,  because  the  living  cells  of  fresh  milk  do  not 
enter  into  the  circulation  direct  as  living  protoplasm,  and 
build  up  the  tissues  direct,  as  they  would  do  in  fresh, 
unboiled  milk.  In  practice  it  will  have  been  noticed  by 
most  medical  practitioners  that  there  is  a  very  distinctly 
appreciable  lowered  vitality  in  infants  which  are  fed  on 
boiled  milk.  The  process  of  absorption  is  more  delayed 
and  the  quantity  of  milk  required  is  distinctly  larger  for 
the  same  amount  of  growth  and  nourishment  of  the  child 
than  is  the  case  when  fresh  milk  is  used. 

Pasteurization  of  Milk. 

Heating  milk  to  75°  C,  as  is  done  by  many  of  the 
methods,  does  not  sterilize,  for  the  spores  of  the  bacillus 
subtilis  can  withstand  this  temperature  for  several  days. 
The  spores  will  resist  the  temperature  of  100°  C.  (212° 
F.)  for  six  hours.  Upon  heating  to  110°  to  120°  C. 
(230°  to  248°  F.)  the  milk  will  be  thoroughly  sterilized, 
but  such  heating  causes  a  browning  of  the  milk,  and  the 
cream-cells  are  apt  to  be  broken  and  the  fat  or  butter  will 
rise  to  the  surface.52 

Pasteurization  with  a  temperature  between  60°  and 

62  Molt-Zeitung. 


STERILIZED  MILK.  173 

80°  C.  (140°  to  176°  F.)  destroys  tubercle  bacilli  and, 
according  to  Van  Geuns,  destroys  also  the  typhoid  ba- 
cillus, the  cholera  bacillus,  and  the  pneumococcus  of 
Friedlander,  and  also  most  of  the  ordinary  milk  germs, 
and  does  not  injure  the  milk.53 

Sterilized  Milk. 

Sterilized  milk  is,  according  to  Marr,54  as  badly  borne 
in  children's  dyspepsias  as  ordinary  milk,  for,  even  when 
sterilized  by  Soxhlet's  apparatus,  milk  is  still  prone  to 
decomposition,  and  hence  favors  the  decomposition-proc- 
esses present  in  the  diseased  digestive  tract. 

Dr.  B.  Bendix55  studied  the  question  as  to  the  rela- 
tive value  of  sterilized  and  unsterilized  milk.  In  a  paper 
recently  published  he  arrives  at  the  following  conclu- 
sions: Sterilized  and  unsterilized  milk  have  an  equal 
value  in  nourishing  both  sick  and  well  children.  The 
change  in  taste  and  odor  caused  by  the  sterilization  is  no 
cause  for  the  refusal  of  the  same  by  infants,  as  steriliza- 
tion destroys  both  the  pathogenic  bacteria,  as  well  as  the 
bacteria  causing  fermentation  and  decomposition;  so  he 
believes  that  it  is  the  duty  of  every  physician  to  insist  on 
substituting  sterilized  milk  when  breast-milk  cannot  be 
had,  and,  as  he  believes  that  sterilization  does  not  cause 
difficulty  of  digestion,  he  prefers  the  latter  to  pasteurized 
milk. 

Koplik56  studied  the  comparative  value  of  sterilized, 
pasteurized,  and  other  milks,  and  found  that  some  weeks 
pasteurized  milk  and  other  weeks  a  sterilized  milk  would 
show  advantages,  which,  however,  would  hardly  decide 
for  or  against  either  method  of  preparing  the  food.  The 
author  believes  that  it  is  rather  the  food  that  should  be 
looked  after  than  the  method  of  feeding  it. 

63  Medical  Record,  July  2,  1892. 

64  London  Medical  Recorder. 
55Jahrbuch  fur  Kinderheilkunde,  38. 

60  New  York  Medical  Journal,  April  13,   1895. 


174  INFANT-FEEDING. 

Sterilization  of  Milk  at  212°  F.  for  Thirty 

Minutes. 

method  of  sterilizing  (soxhlet  method). 

Bottle-cleansing.  —  Always  cleanse  the  bottles  thor- 
oughly before  using  if  they  are  new  bottles.  It  is  a  good 
plan  to  give  them  one  good  washing  by  adding  a  pinch  of 
common  washing-soda  to  each  bottle,  boiling  for  at  least 
five  minutes  in  this  soda-water,  and  then  boiling  for  at 
least  a  quarter  of  an  hour  in  ordinary  water.  The  bottles 
are  then  turned  upside  down  to  allow  the  water  to  drain 
off.  I  then  insert  a  large  stopper  consisting  of  non- 
absorbent  cotton  (ordinary  cotton,  from  a  dry-goods  store, 
which  is  non-absorbent,  is  far  better  than  the  white  ab- 
sorbent cotton).  The  neck  of  the  bottle  is  stoppered  at 
least  three-quarters  of  an  inch. 

Bottle-oaJeing.  —  If  we  wish  to  dry  them  hurriedly, 
then  several  of  these  bottles  can  be  placed  in  a  large 
frying-pan  with  a  piece  of  pasteboard  between  each  bottle, 
and  baked  thoroughly  dry  for  about  a  half-hour..  This 
not  only  dries  them,  but  baking  them  really  sterilizes 
them. 

Place  the  bottles — previously  filled  with  milk  or  the 
feeding  mixture — in  the  rack,  and  set  the  rack  in  the 
sterilizing  chamber,  and  cover  up  tight  with  the  lid  and 
hood. 

Fill  the  reservoir  (pan)  two-thirds  full  of  water  and 
place  the  apparatus  over  a  moderate  fire  for  one  hour. 
If  the  milk  is  just  from  the  cow,  40  or  50  minutes  are 
sufficient  (20  minutes  for  heating  and  20  or  30  minutes 
for  sterilizing). 

The  sterilizer  may  be  used  on  a  gas-stove  (turned 
low),  kerosene-stove,  or  upon  an  ordinary  cooking-stove; 
if  over  the  last,  the  griddle  should  not  be  removed.  You 
can  tell  by  a  bubbling  sound  that  the  sterilizer  is  working 
all  right.  If  the  water  is  not  bubbling  with  regularity  in- 
side, you  need  more  heat.    It  must  not  be  put  on  the  fire 


STERILIZATION  OF  MILK. 


175 


without  water  in  the  reservoir,  and  the  water  should  never 

be  allowed  to  get  lower  than  one  inch  from  the  bottom. 

With  proper  attention  as  to  the  quantity  of  water  in 

the  reservoir  no  further  care  need  be  given  to  the  appara- 


Fig.  23. 


tus,  or  to  the  contents  of  the  chamber,  for  the  prescribed 
time. 

It  is  not  necessary  to  place  the  bottles  on  ice  after 
removing  them  from  the  sterilizer,  but  all  bottles  should 


176 


INFANT-FEEDING. 


be  put  into  a  refrigerator  until  taken  out  for  feeding, 
leaving  in  the  cotton  plugs  until  it  is  feeding-time.  The 
directions  sent  out  with  some  sterilizers,  that  milk  will 
keep  for  days,  implies  that  infant's  milk  may  be  prepared 
for  several  days  at  once.  To  this  I  decidedly  object.  A 
great  many  authors  have  pointed  out  cases  of  Barlow's 
disease  due  to  milk  which  had  been  sterilized  and  not  used 


Fig.  24. 


for  a  very  long  time.  Before  feeding,  the  bottle  is  to  be 
properly  warmed  by  putting  it  into  a  small  measure  or 
bottle-holder  and  heating  it  with  alcohol  or  gas  to  about 
the  body-temperature  of  98°  or  100°  F.  Immediately  be- 
fore using  shake  the  bottle,  so  as  to  mix  the  cream  and  the 
milk,  which  invariably  separate  in  a  refrigerator;  remove 
the  cotton  and  draw  on  the  nipple. 


CHAPTEE  XXV. 


Pasteurized  Milk. 


Booker  states  that  certain  germs  may  not  be  harm- 
ful to  the  baby,  if  introduced  into  its  body,  but  are  in- 
jurious to  the  milk.  For  example,  bacillus  lactis  aerog- 
enes.  These  germs  are  destroyed  at  a  low  temperature. 
Booker  does  not  believe  that  the  disturbances  claimed  to 
be  caused  by  the  sterilization  of  milk  are  warranted;  nor 
does  he  believe  that  sterilized  milk  per  se  causes  scurvy. 

Preeman  states  that  high-temperature  sterilization 
causes  chemical  changes  in  milk: — 

Change  in  taste  at 70°  C.  (158°  F.). 

Chemists  note  changes  at  about 80°  C.   (176°  F.). 

Preeman  believes  bottle-food  to  be  a  predisposing 
cause  of  scurvy.  He  states  that  a  low  temperature,  pro- 
longed, acts  as  well  in  destroying  pathogenic  germs  as 
the  action  of  a  high  temperature  for  a  short  time.  He 
advises  68°  C,  equivalent  to  155°  F.,  for  30  minutes, 
followed  by  rapid  cooling.  Such  a  temperature  will  de- 
stroy the  germs  of  diphtheria,  typhoid,  tuberculosis,  and 
other  diseases,  proved  by  the  inoculation  of  a  plate  at 
laboratory  temperature,  showing  no  growth  after  twenty- 
four  hours.  Preeman  does  not  believe  that  our  present 
dairy  can  furnish  a  raw  milk  which  is  absolutely  safe  as 
an  infant-food,  because,  he  says,  milk  must  be  obtained 
by  pressure  on  the  teats  of  a  cow,  and  these  teats  hang 
beneath  an  udder,  which  is  covered  with  hair,  and  from 
the  belly  of  the  cow,  which  is  also  covered  with  this  same 
hair  covering.  Moreover,  this  portion  of  a  cow  is  par- 
ticularly liable  to  be  soiled  with  dirt,  as  it  comes  in  con- 
tact with  the  ground  when  the  cow  lies  down.    Its  hairy 

12  (177) 


178  INFANT-FEEDING. 

covering,  moreover,  holds  the  dirt,  which  is  gradually 
shaken  out  by  friction.  If  the  cow  has  loose  stools,  these 
run  down  the  inner  surface  of  the  thigh  and  the  posterior 
portion  of  the  udder.  The  contamination  dries  on  the 
udder,  in  the  air,  and  during  milking  is  apt  to  fall  as 
dust  in  the  pail.  Moreover,  the  milk-ducts  of  the  cow 
may  contain  many  bacteria,  although  usually  contami- 
nation from  this  source  is  not  very  great.  Freeman  fur- 
ther says:  "The  milkman's  hands  are  almost  never  clean. 
His  hands  are  employed  in  handling  manure,  and  in 
attending  duties  involving  contamination.  Occasionally 
they  are  used  during  the  day  in  waiting  on  some  one 
sick  with  a  contagious  disease,  and,  when  such  is  the  case, 
the  consumers  of  the  milk  are  apt  to  suffer." 

The  author  read  a  paper  by  Prof.  Adolf  Baginsky, 
on  "The  Milk-supply  in  the  Kaiser  and  Kaiserin  Fried- 
rich  Children's  Hospital,  in  Berlin,"  before  the  Section 
on  Diseases  of  Children,  at  Atlantic  City,  in  June,  1900, 
wherein  Baginsky  says  that,  before  milking  a  cow,  the 
stable  is  cleaned  with  a  damp  cloth.  All  the  dirt  is  re- 
moved, and  finally  the  stable  is  cleaned  with  water.  Prior 
to  milking,  the  Swiss  milkmen  are  compelled  to  thor- 
oughly cleanse  themselves,  giving  especial  attention  to 
their  hands.  These  are  cleaned  with  soap  and  brush. 
Great  stress  is  laid  on  washing  the  udder  of  each  animal 
with  warm  soap-water,  and  drying  with  clean  cloths.  In 
this  manner  the  infection  with  hair  and  stable-dirt  is  pre- 
vented. The  milk  is  not  allowed  to  remain  in  the  stable 
until  all  the  cows  are  milked,  but  as  soon  as  a  pail  is  filled 
it  is  at  once  removed  to  the  dairy,  thus  preventing  the 
danger  of  contamination  with  bacteria  which  are  found 
in  the  air  of  the  stable  and  which  are  very  hard  to  destroy 
by  sterilization.  These  are  the  bacteria  of  the  hay-  and 
potato-  bacillus  groups.  Another  vital  point  is  that  warm 
milk  easily  absorbs  the  various  stable-odors,  and  frequently 
has  a  distinct  "stable-flavor." 

If  what  Freeman  claims  might  happen,  —  namely: 


PASTEDEIZED  MILK. 


179 


the  introduction  of  filth,  manure,  and  f cecal  matter  into 
the  milk  during  the  milking  process, — then  it  seems  to 
me  that  such  milk  should  be  discarded  entirely,  for  it  is 
hardly  conceivable  that  sterilizing  or  pasteurizing  can 
modify  milk  contaminated  in  such  a  manner.  Following 
the  precepts  of  Professor  Baginsky  at  Berlin,  the  main 
point  is  to  insist  on  the  strictest  "stable-hygiene,"  and 
thus  try  to  sterilize  everything  pertaining  to  the  cow, 
the  stable,  and  the  utensils,  and  in  this  manner  seek  to 
obtain,  by  the  strictest  attention  to  cleanliness,  "a  strictly 
clean  milk." 


Fig.  25. — Author's     Choice  of  Feeding-bottle. 


Directions  for  Pasteurizing  Milk. — Pasteurization  is 
really  sterilization  at  a  temperature  of  167°  P.  Experi- 
ence has  shown  that  the  bacteria  usually  found  in  milk 
and  those  which  would  be  harmful  for  an  infant  can  be 
destroyed  by  subjecting  milk  to  a  temperature  of  167° 
to  170°  F.  for  15  to  20  minutes.  For  this  purpose  Free- 
man has  constructed  his  pasteurizing  apparatus  (see  Figs. 
26  and  27),  which,  however,  is  rather  expensive,  although 
extremely  useful.  The  author  has  used  it  and  has  been 
well  pleased  with  the  result. 


180 


INFANT-FEEDING. 


Freeman's  pasteurizer  consists  of  a  metal  pail  into 
which  a  rack  is  placed  holding  the  bottles  exactly  as  is 
found  in  the  ordinary  sterilizing  apparatus.  This  metal 
pail  is  partly  filled  with  water — up  to  its  first  groove — and 
the  water  heated  to  the  boiling-point.  Until  the  water  is 
brought  to  the  boiling-point,  the  bottles  are  not  intro- 
duced within  the  kettle.  The  bottles,  previously  filled 
with  the  required  mixture  of  the  infant's  food,  are  held 
in  readiness,  and,  when  the  water  boils  in  the  metal  pail, 
the  lid  is  removed,  the  rack  with  the  bottles  placed  on 
the  inside  of  the  metal  pail,  and  the  heat  turned  off,  or  the 
pail  is  removed  from  the  fire.     The  process  consists  in 


Fig.  26. 


allowing  the  water  to  cool,  whereby  the  bottles  and  the 
milk  get  warm  for  a  period  of  30  to  45  minutes.  After 
45  minutes,  the  lid  is  again  removed,  the  metal  pail  con- 
taining the  bottles  of  milk  is  taken  to  a  water-trough  or 
sink,  and  the  cold-water  faucet,  over  which  a  piece  of  rub- 
ber pipe  is  fitted,  is  turned  on,  and  the  water  permitted  to 
flow  on  the  inside  of  the  pasteurizer.  In  this  way  there 
is  a  gradual  displacement  of  the  warm  water  by  this  cold 
water,  until  the  water  is  all  cold. 

After  the  bottles  are  sufficiently  cooled,  they  should 
be  removed  to  the  refrigerator.  The  rapid  cooling  of  the 
bottles  is  as  important  as  the  pasteurization  by  the  heat. 
Pasteurized  milk  should  be  kept  no  longer  than  twenty- 


PASTEURIZED  MILK. 


181 


four  hours.  We  can  pasteurize  in  other  ways  with  any 
ordinary  sterilizing  apparatus.  Thus,  the  Arnold  steam- 
sterilizer  (see  Fig.  23),  leaving  the  hood  off,  can  be  util- 
ized for  this  purpose.  To  be  sure  that  we  are  attaining 
the  correct  temperature,  we  can  insert  a  special  ther- 
mometer, which  is  made  for  sterilizing  bottles.  It  can  be 
procured  from  any  chemist  or  from  the  Arnold  Sterilizer 
Company. 

To  pasteurize  with  any  ordinary  sterilizer,  set  a  ther- 
mometer into  one  bottle  and  put  the  sterilizer  on  a  brisk 
fire  until  the  thermometer  reaches  170°  F.    Then  remove 


Fig.  27. 


to  the  back  of  the  stove,  take  out  the  thermometer,  stopper 
the  bottle  that  contained  the  same,  and  cover  with  a  hood 
or  the  lid  of  the  tin  pail  for  fifteen  minutes.  Then  fill 
the  inside  of  the  pail  with  hot  water  around  the  bottles 
as  near  to  the  top  as  possible,  remove  to  the  sink,  and  allow 
a  stream  of  cold  water  from  the  faucet  to  displace  the 
warm  water.  A  point  worth  noting  is  that  the  cold  water 
must  not  be  allowed  to  splash  on  the  hot  bottles,  other- 
wise it  will  crack  them.  It  usually  takes  about  ten  min- 
utes to  gradually  displace  the  hot  water  in  the  tin  pail  or 
kettle  used  as  a  sterilizing  chamber,  after  which  the  bottles 
of  milk  are  to  be  placed  in  a  refrigerator  and  left  there 


182  INFANT-FEEDING. 

until  ready  for  use.  It  is  understood  that  each  bottle  is 
to  be  warmed  to  about  a  body-temperature  of  98°  to  100° 
immediately  before  feeding. 

In  a  letter  recently  received  by  the  author  Prof. 
Victor  Vaughan  says  he  does  not  believe  that  milk  is 
rendered  more  digestible  by  sterilization  or  pasteurization. 
He  thinks  that  if  milk  could  be  obtained  under  complete 
aseptic  precautions,  sterilization,  as  a  preparation  for  in- 
fant-feeding, would  not  be  necessary.  However,  either 
sterilization  or  pasteurization  is  imperative  when  market 
milk  is  used,  because  this  is  seldom  or  never  obtained 
under  aseptic  precautions.  Some  people  have  an  idea  that 
it  matters  not  how  filthy  a  milk  is,  or  how  many  germs 
it  may  contain,  if  it  be  pasteurized  or  sterilized  it  becomes 
a  fit  food  for  children.  This  is  not  true,  because,  in  the 
first  place,  even  prolonged  boiling  does  not  kill  the  spores 
of  all  bacteria;  and,  in  the  second  place,  the  chemical 
poisons  produced  by  certain  germs  are  not  altered  by  the 
temperature  of  boiling  milk.  After  milk  has  been  either 
sterilized  or  pasteurized  it  should  be  kept  at  a  low  tem- 
perature before  being  fed  to  the  child.  This  should  be 
regarded  as  a  necessary  procedure  in  the  preparation  of 
infant-food.  The  fact  that  milk  in  which  the  colon  germ 
has  already  grown  abundantly  cannot,  by  any  process  of 
sterilization  or  pasteurization,  be  rendered  fit  food  for 
children  should  be  emphasized.  The  toxin  of  the  colon 
bacillus  may  be  heated  to  180°  C.  (356°  F.)  for  half  an 
hour  without  having  its  poisonous  properties  diminished. 
If  clean  milk  be  obtained  and  pasteurized  at  from  140° 
to  158°  C.  and  then  kept  at  a  low  temperature  until  fed 
to  the  child,  it  furnishes  the  best  food  which  it  is  possible 
for  us  to  obtain  under  ordinary  circumstances. 


CHAPTER  XXVI. 

Tyndallization. 

"When  milk  is  subjected  to  a  temperature  of  212°  F. 
for  from  15  to  20  minutes  on  three  successive  days,  such 
process  is  called  tyndallization.  When  such  a  procedure 
is  instituted,  we  certainly  obtain  the  "absolutest  sterility 
possible"  of  the  milk. 

Such  milk,  however,  is  not  adapted  for  infant-feeding, 
owing  to  the  changes  brought  about  by  this  continued 
application  of  heat  in  rendering  the  albuminoids  and  salts 
contained  in  the  milk  more  difficult  to  digest. 

Milk  subjected  to  this  tyndallization  has  all  the  dis- 
advantages of  a  prolonged  sterilized  milk  or  milk-mixture. 
My  experience  is  decidedly  against  such  continued  heating 
of  milk,  and  I  am  sure  that  many  cases  of  scurvy  can  be 
traced  to  the  lack  of  fresh  albumin  and  casein  assimilated. 

It  is  certainly  peculiar  that  in  spite  of  the  experience 
of  many  noted  men,  the  author  has  recently  seen  a  de- 
cided improvement  in  a  child  suffering  with  scurvy  when 
the  food  was  changed  from  sterilized  milk  to  a  raw-milk 
mixture,  the  milk-mixture  being  merely  warmed  to  a  feed- 
ing temperature. 

Barlow's  disease  can  frequently  be  traced  to  improper 
feeding,  especially  when  mothers  are  permitted  to  use 
their  experience  in  making  up  their  own  feeding-mixtures. 
Children  are  more  frequently  starved  than  will  be  ordi- 
narily admitted,  and,  were  it  possible  to  examine  the  food 
given  to  the  average  infant  and  compare  it  with  a  stand- 
ard breast-milk  suited  for  the  age  of  the  infant,  we  would 
soon  learn  that  our  crude  methods  resulted  in  positive 
harm,  the  result  of  which  years  of  proper  medication  and 
feeding  will  hardly  be  able  to  remedy. 

(183) 


184  INFANT-FEEDING. 

The  vital  point  to  remember  is  to  get  the  child  prop- 
erly started,  and  we  must  not  be  discouraged  if  our  first 
feeding-mixture  is  not  properly  digested  or  assimilated. 
In  such  instances  we  will  soon  learn  which  elements  of 
our  food  require  more  proper  modification  and  elimina- 
tion, especially  so  if  the  stools  are  studied. 

Tyndallization  will  permit  milk  to  be  kept  for  months, 
and  is  just  such  milk  which,  fed  to  weakened  children,  will 
ultimately  cause  Barlow's  disease  or  its  allied  conditions. 
While  in  Berlin  several  years  ago  I  was  given  milk  which 
had  been  sterilized  six  months  previously.  While  it  is 
true  the  taste  did  not  betray  the  length  of  time  that  the 
milk  had  been  kept,  it  can  be  easily  seen  that  certain 
chemical  changes  will  develop,  altering  the  character  of 
the  food. 

It  is  my  belief,  founded  on  extensive  experience,  that 
sterilized  milk,  continually  fed,  to  the  exclusion  of  raw 
milk  and  raw  beef-juice,  will  ultimately  result  in  rachitis 
or  scurvy. 


CHAPTEK  XXVII. 

Nipples  and  Bottles. 

Attention  to  this  portion  of  the  feeding  apparatus  is 
very  important,  as  the  cause  of  sore  mouth  and  tongue 
and  gums  can  frequently  be  traced  to  a  filthy  nipple. 


CM 


Fig.  28. 


Such  infections  can  he  easily  avoided  in  the  following 
manner:  The  nipples  are  to  be  boiled  for  about  ten  or 
fifteen  minutes  in  a  so-called  nipple-sterilizer  (see  illus- 


tration, Pig.  32),  placed  in  a  tin  pail  of  plain  water  to 
which  a  pinch  of  salt  has  been  added.  After  boiling  in 
this  manner  the  nipple  should  be  put  into  a  tumbler  of 
plain,  sterilized  (boiled)  water  and  allowed  to  soak  until 

(185) 


18G 


INFANT-FEEDING. 


it  is  time  to  use  it.  It  is  advisable  to  boil  every  nipple 
immediately  after  removing  it  from  the  feeding-bottle, 
turning  it  inside  out,  placing  it  in  the  sterilizer,  and 
steaming  it  for  15  or  20  minutes.     In  this  manner  all 


Fig.  30. 


Fig.  31. 


pathogenic  bacteria  are  destroyed,  and  all  particles  of  milk 
which  adhere  to  the  rubber  are  removed.  Such  nipples 
will  not  be  the  cause  of  stomatitis  or  other  infectious 
mouth  disorders. 


NIPPLES  AND  BOTTLES.  187 

The  clioice  of  a  nipple  is  another  important  matter. 
My  preference  has  always  been  for  a  black-rubber  nipple, 
and  it  is  a  very  wise  point  to  use  a  nipple  no  longer  than 
one  week;  in  other  words,  old,  worn  nipples  are  useless 
for  the  proper  management  of  infant-feeding.  Black 
rubber  is  softer  than  white  rubber;  most  white  rubber 
is  supposed  to  contain  lead;  hence  a  decided  reason  for 
not  using  it. 

Nipples  Recommended. — One  of  the  best  nipples  made 
is  the  so-called  anticolic  nipple.  This  nipple  has  a  ball- 
shaped  top,  which  enables  a  baby  to  take  a  firm  hold;  it 
has  three  small  holes,  which  give  an  easy  flow  of  milk, 
and  regulate  a  slow  meal.  Nipples  having  very  large 
openings,  which  will  permit  a  baby  to  finish  a  6-  or  8- 
ounce  bottle  of  food  in  five  or  six  minutes,  are  useless, 
and  this  gulping  of  food  is  really  the  cause,  or  one  of  the 
causes,  of  infantile  colic. 

I  have  used  another  nipple,  but  it  is  much  harder  to 
clean,  and  unless  all  precautions  for  sterilization  are  care- 
fully noted  it  should  not  be  used;  yet,  in  the  hands  of  the 
intelligent  or  where  we  have  a  trained  nurse,  it  can  be 
safely  recommended.  It  is  called  the  "Mizpah."  This 
nipple  has  also  a  very  small  puncture,  so  that  the  baby 
gets  the  food  slowly. 

The  "swan-bill"  nipple  and  the  long  French  nipple  I 
also  like.  I  have  noted  just  as  good  results  as  with  the 
above-mentioned  kinds. 

Ventilated  Nipple. — A  nipple  very  highly  spoken  of 
is  the  ventilated  nipple  made  by  Ware,  of  Philadelphia, 
which  has  a  small  opening  or  valve  on  the  side,  and,  as 
the  milk  is  drawn  in  from  the  bottle,  it  permits  air  to 
enter,  thus  preventing  a  vacuum  from  being  formed.  It 
is  also  supposed  to  be  non-collapsible,  and  is  highly  rec- 
ommended by  those  who  have  used  it.  The  only  objec- 
tion— already  offered — is  that  all  nipples  must  not  only 
be  practical  for  use,  but  must  be  capable  of  thorough 
sterilization. 


188 


INFANT-FEEDING. 


Odor  of  Nipples.  —  Children  will  object  most  de- 
cidedly to  nipples  having  any  odor  or  taste;  hence  it  is  a 
good  plan  to  boil  every  new  nipple  before  using  it. 


Fig.  32. — Nipple-sterilizer. 


The  nipple-sterilizer  (see  Fig.  32)  is  a  very  conven- 
ient little  arrangement  made  by  Ware,  of  Philadelphia, 
and  resembles  a  coffee-strainer  with  a  lid.     It  is  neat, 


tf*™^*, 


cheap,  and  serves  its  purpose  admirably  for  the  steriliza- 
tion of  the  nipple. 

The  bottle-brush  has  a  long  handle  and  bristles  for 
cleansing  the  bottles.     This  brush  should  be  used  before 


Fig.  34.— Bottle-brush. 


the  bottles  are  put  in  the  soda  solution,  and  serves  for 
cleansing  the  inside  of  the  feeding-bottles.  It  is  un- 
derstood that  the  brush  can  itself  harbor  bacteria  and 
particles  of  milk  removed  while  cleansing.    It  is  therefore 


FEEDING-BOTTLES. 


189 


important  that  the  brush  should  be  thoroughly  boiled  in 
a  washing-soda  solution  after  each  use. 


Fig.  35. 

Feeding-bottles. 

The  long  8-ounce  feeding-bottle,  or  so-called  feeding- 
tube,  which  is  illustrated,  is  certainly  a  unique  bottle  for 
feeding;   as  it  has  no  corners  and  no  useless  rims,  besides 


Fig.  36. 


being  smooth  on  the  inside,  it  can  be  very  easily  cleaned. 
All  bottles  having  angles  and  depressions  should  be 
avoided.  The  boat-shaped  bottle  is  also  very  good,  but 
much  harder  to  clean. 


190  INFANT-FEEDING. 

My  preference  has  always  been  for  two  kinds  of 
bottles:  1.  Those  holding  four  ounces  and  graduated  on 
one  side  in  both  ounces  and  tablespoons;  this  saves  much 
time  and  trouble.  2.  Bottles  holding  eight  ounces  and 
divided  off  into  16  tablespoonfuls  or  8  equal  ounces. 

Exactness  of  Ounces. — It  may  not  be  out  of  place 
to  ask  each  physician  to  insist  on  having  the  graduated 
ounces  on  an  infant's  feeding-bottle  measured  with  an 


Fig.  37. — Baby-comforter.     Not  Advised  by  tbe  Author. 

accurate  graduate,  obtainable  at  every  drug-store.  In 
many  instances  the  author  noted  feeding-bottles  wherein 
the  ounces  indicated  were  very  unequal,  and  one  partic- 
ular bottle,  graduated  to  eight  ounces,  held  twelve  ounces. 
Long  Rubber  Tubes.  —  Most  prominent  pediatrists 
agree  that  the  long  rubber  tubes  are  a  convenient  place 
for  harboring  micro-organisms,  and  they  have  been  uni- 
versally condemned. 


CHAPTER  XXVIII. 


Dextrinized  Gruels. 


We  have  previously  referred,  in  the  section  on  "Addi- 
tional Foods  during  the  "Nursing  Period/'  to  the  method 
of  making  flour-ball.  In  some  instances,  especially  where 
digestion  is  subnormal,  beneficial  results  will  follow  the 
dextrinizing  of  infant-foods.  Thus,  the  starch  of  the 
gruel  is  held  in  solution,  and  the  remaining  cellulose  and 
proteids  of  the  cereal  are  left  to  act  on  the  curds. 

Method  of  Dextrinizing. — Prepare  the  wheat-,  barley-, 
oatmeal-,  or  rice-  flour  by  adding  a  tablespoonful  of  the 
same  to  a  pint  of  water,  adding  a  pinch  of  salt,  and  boiling 
the  same  for  from  fifteen  minutes  to  one  hour.  This  will 
make  a  gelatinous  solution,  and  hence  the  name  of  barley- 
jelly,  rice-jelly,  oatmeal-jelly,  or  wheat-jelly.  "We  allow 
this  jelly  to  cool,  and  when  cool  enough  to  be  tasted  we 
can  add  a  diastase,  such  as  cereo;  or  taka-diastase,  made 
by  Parke,  Davis  &  Co. ;  or  the  Forbes  diastase.  When  a 
small  quantity  of  this  diastase  is  added  to  the  jellies  above 
mentioned,  they  lose  their  thickness,  and  become  very 
thin.  They  can  easily  be  strained  through  cheese-cloth, 
and  some  water  added  to  make  up  for  the  loss  by  evapora- 
tion during  the  boiling.  This  jelly,  or  gruel  as  it  is  some- 
times called,  made  from  either  barley-,  rice-,  wheat-,  or 
oat-  jelly,  is  to  be  used  with  the  milk  after  the  diastase  is 
added.  In  certain  diseases,  where  milk  is  not  well  borne, 
such  as  dyspepsia  (dyspeptic  vomiting)  or  in  summer  com- 
plaint, where  the  giving  of  milk  is  prohibited,  feeding  the 
dextrinized  gruels  for  several  days  will  be  found,  not  only 
very  useful,  but  very  healthful.  In  making  this  dex- 
trinized gruel,  small  particles  will  be  seen  floating,  which 
settle  out  upon  standing.     These  particles  consist  of  the 

(191) 


192  INFANT-FEEDING. 

cell-walls  and  the  proteids  of  the  cereal,  and  cut  the  curds 
of  the  milk  into  fine  pieces,  when  the  curds  begin  to 
shrink  under  the  combined  action  of  rennet  and  acid.  In 
using  this  diastase  we  aim  at  breaking  up  the  tough  curd 
in  cows'  milk  by  purely  mechanical  means. 

Henry  D.  Chapin  {Journal  of  the  American  Medical 
Association,  July  14,  1900)  says:  "The  next  important 
step  is  to  get  the  cows'  milk  as  nearly  as  possible  in  the 
same  physical  condition  as  mothers'  milk.  The  diluent  I 
prefer  to  use  is  a  wheat-,  barley-,  or  oatmeal-  gruel,  the 
starch  of  which  has  been  digested  or  dextrinized  by  the 
action  of  diastase.  A  heaping  tablespoonful  of  flour,  made 
from  a  cereal,  is  boiled  with  about  a  pint  and  a  half  of 
water  for  fifteen  minutes.  It  is  then  removed  from  the 
stove  and  set  in  cold  water  for  about  three  minutes  to  cool 
it.  When  it  is  sufficiently  cool  to  taste,  a  teaspoonful  of 
a  preparation  of  diastase  is  added,  which  renders  the  gruel 
thin  and  watery.  This  makes  about  a  pint  of  gruel,  con- 
taining the  starches  in  soluble  form,  while  the  cellulose, 
or  skeleton  of  the  cereal,  acts  as  a  most  effective  attenu- 
ant  of  the  curd.  These  digested  gruels  render  the  milk- 
curd  porous,  and  also  provoke  the  secretion  of  the  digest- 
ive juices.  As  diluents,  they  are  a  great  improvement  on 
water.  Most  of  the  thick  malt-extracts  are  sufficiently 
active  in  diastase  to  produce  the  desired  effect."  The 
writer,  however,  prefers  the  employment  of  diastase  itself, 
without  any  of  the  other  malt  ingredients,  as  being  both 
speedy  and  efficient.  It  can  either  be  produced  cheaply  at 
home  or  purchased  at  the  nearest  drug-store.  A  simple 
decoction  of  diastase  may  be  made  as  follows:  A  table- 
spoonful  of  malted  barley-grains  is  put  in  a  cup,  and 
enough  cold  water  added  to  cover  it,  usually  two  table- 
spoonfuls,  as  the  malt  quickly  absorbs  some  of  the  water. 
This  is  prepared  in  the  evening  and  placed  in  the  re- 
frigerator over  night.  In  the  morning  the  water,  looking 
like  thin  tea,  is  removed  with  a  spoon  or  strained  off,  and 
is  ready  for  use.     About  a  tablespoonful  of  this  solution 


DEXTRIXIZED  GRUELS.  193 

can  be  thus  secured,  and  is  very  active  in  diastase.  It  is 
sufficient  to  dextrinize  a  pint  of  gruel  in  ten  to  fifteen 
minutes.  Preparations  of  diastase  are  made  by  a  number 
of  chemists:  Forbes;  Parke,  Davis  &  Co.;  Horlick,  and 
others.  There  is  now  obtainable  an  active  glycerite  of 
diastase  known  as  cereo,  which  is  specially  made  for  the 
purpose  of  dextrinizing  gruels. 

During  the  past  summer,  in  those  critical  cases  of  sum- 
mer complaint  in  which  subnormal  digestion  existed,  the 
author  has  seen  very  good  results  follow  the  administra- 
tion of  any  and  all  of  the  malt-extracts  now  in  our  market. 

Frequently  the  administration  of  a  teaspoonful  of 
malt-extract  to  an  infant  immediately  before  feeding  was 
not  only  relished  by  the  infant  on  account  of  the  pleasant 
taste  of  the  malt,  but  certainly  aided  in  the  assimilation 
of  the  food.  Rarely  was  more  than  3  teaspoonfuls  of  malt 
ordered  during  twenty-four  hours.  Such  preparations  as 
maltine  and  also  maltzyme  gave  very  good  results.  The 
malt-extract  of  Parke,  Davis  &  Co.  has  a  very  pleasant 
flavor  and  seems  well  borne. 

Frequently,  when  expense  proved  an  important  item, 
sufficient  dextrinization  of  foods  could  be  procured  with 
these  malt  preparations  above  cited. 

It  is  claimed  by  some  that  most  malt  preparations  de- 
teriorate on  standing  or  if  exposed  too  long;  this  is  cer- 
tainly untrue. 


PART  II. 


CHAPTER  XXIX. 

Feeding  of  Infants  in  Incubators. 

"When  we  consider  that  the  usual  viability  of  a  child 
is  placed  at  twenty-eight  weeks  of  intra-uterine  gestation, 
then  we  can  see  how  vastly  different  the  method  of  feed- 
ing must  be  from  that  of  a  child  born  at  term,  or  a  so- 
called  "full-born  child." 

Method  of  Feeding. — The  size  of  the  child  precludes 
the  taking  of  an  ordinary-sized  nipple,  and  hence  various 
measures  have  been  tried,  the  most  successful  of  which 
has  been,  according  to  the  author's  experience,  feeding 
with  a  small  medicine-dropper  at  intervals  of  two  hours, 
the  quantity  varying  with  the  age  of  the  infant.  It  is 
a  good  plan,  considering  the  capacity  of  the  infant  at 
term  to  be  1  ounce,  to  recognize  the  deficiency  in  the 
development  of  not  only  the  size  and  capacity  of  the 
stomach,  but  also  its  lack  of  digestive  function.  Hence 
my  plan  has  been  to  commence  feeding  by  giving  two 
teaspoon fuls  of  milk  diluted  with  two  teaspoonfuls  of 
sugar-water;    no  lime-water  and  no  salt  added. 

A  prematurely  born  baby  is  necessarily  doomed  with- 
out proper  food,  and  there  are  so  many  other  factors  to 
be  considered  during  its  life  in  an  incubator,  such  as  its 
ventilation,  its  bodily  warmth  and  cleanliness,  that  too 
much  stress  cannot  be  laid  on  the  value  of  its  food.  With- 
out breast-milk,  therefore,  I  feel  justified  in  saying:  I 
have  yet  to  see  the  premature  infant  that  will  survive, 
and  hence  I  advise  procuring  breast-milk,  containing  no 
colostrum-corpuscles,  from  a  woman  having  a  child  any- 
(194) 


FEEDING  OF  INFANTS  IN  INCUBATORS.       195 

where  from  two  or  three  weeks  to  several  months  old,  and 
diluting  this  breast-milk,  as  stated  above,  with  a  solution 
of  cane-  or  milk-  sugar.  Voorhees57  says:  "Regarding 
the  care  of  premature  babies  in  incubators,  we  have  relied 
mainly  on  diluted  breast-milk,  and  have  only  employed 
cows'  milk  in  weak  proportions  when  it  was  impossible 
to  obtain  the  former.  In  our  opinion,  our  results  would 
have  been  much  poorer  without  the  help  of  mothers' 
milk." 

In  rare  instances,  where  infants  are  very  weak,  and 
seem  to  doze  and  will  not  swallow,  a  No.  7-American 
Tiemann  &  Co.  rubber  catheter,  having  a  velvet  eye,  can 
be  attached  to  a  long  rubber  tube  about  one  foot  in  length 
and  ending  in  a  little  funnel,  holding  several  ounces. 
(See  illustration,  Fig.  40.)  With  this  funnel  and  catheter 
forced  feeding  ■ — ■  so-called  gavage  —  can  be  performed. 
With  the  infant  lying  flat  on  its  back,  push  the  catheter 
slowly,  but  forcibly,  through  the  mouth  as  far  against 
the  pharynx  as  possible,  and  continue  to  push  the  tube 
from  the  pharynx  into  the  oesophagus  and  the  stomach. 
In  all,  from  five  to  seven  inches,  rarely  more,  will  be 
necessary  to  reach  the  stomach.  The  milk,  properly  di- 
luted with  an  equal  quantity  of  milk-sugar  solution,  can 
then  be  allowed  to  flow  into  the  stomach,  and  the  cath- 
eter must  then  be  very  quickly  withdrawn.  Such  feeding 
should  be  repeated  once  in  four,  five,  or  six  hours,  de- 
pending on  the  requirements  of  the  case.  Each  infant  is 
a  law  unto  itself,  and  hence  no  cast-iron  rule  can  be  laid 
down,  but  each  individual  case  should  be  studied  sepa- 
rately and  its  requirements  met  as  indicated.  Thus  I 
have  found  in  a  premature  infant,  born  at  seven  months, 
that  6  drachms  was  enough  for  one  feeding,  and  this  was 
well  borne  once  in  three  hours.  The  food  consisted  of 
equal  parts  of  breast-milk  and  milk-sugar  water.  This 
feeding  was  continued  for  one  week,  when  the  child  cried 


"Archives  of  Pediatrics,  May,  1900. 


196  INFANT-FEEDING. 

very  much,  and,  on  attempting  to  satisfy  it,  the  infant 
swallowed  1  1/2  ounces.  We  then  alternated  each  feeding 
by  giving  a  large  meal  of  1 1/2  ounces  followed  by  a  small 
meal  of  6  drachms,  and  fed  in  this  manner  every  two 
hours  until  the  child  was  three  weeks  old.  We  then  gave 
1 1/2  ounces  of  food  every  two  hours.  The  child's  stool 
was  quite  good;  it  soiled  from  two  to  three  napkins  every 
day,  and,  when  it  was  very  restless,  we  gave  it  from  2  to 
3  teaspoonfuls  of  boiled  water,  which  seemed  to  satisfy 
it.  I  would  urge  the  necessity  of  giving  plain,  sterilized 
water  freely  to  all  infants  living  in  an  incubator.  The 
increased  temperature  of  its  surroundings  calls  for  it;  so 
does  also  the  necessity  for  eliminating  through  skin,  bow- 
els, and  kidneys. 

Dangers  of  Feeding. — Yery  small  quantities  of  food 
should  be  used  in  gavage — feedings  of  the  mouth  or  when 
feeding  through  the  nose.  No  more  than  4  to  6  drachms 
should  be  used,  and  thus  we  can  feel  our  way.  It  is  a 
good  point  to  remember  that,  the  pharynx  being  very 
sensitive,  the  irritation  of  the  tube  in  passing  into  the 
stomach  may  provoke  regurgitation  of  some  of  this  food, 
and  frequently  vomiting  will  be  produced.  In  such  in- 
stances, if  the  posterior  nares  or  the  pharynx  is  filled 
with  food,  the  infant  can  easily  suck  some  of  this  fluid 
during  an  inspiration  into  its  trachea,  and  start  up  a  pneu- 
monia in  the  same  manner  as  is  done  by  a  child  having  a 
tube  in  the  larynx  in  the  treatment  of  laryngeal  stenosis. 

Rectal  feeding  for  premature  infants  is  rarely  called 
for,  but  it  can  and  should  be  tried  if  the  infant  will  not 
swallow  and  the  forced  feeding  through  the  mouth  or  nose 
is  unsuccessful.  In  such  instances  use  very  dilute  milk, 
thoroughly  peptonized, — the  same  proportions,  however, 
as  have  been  stated  previously,  namely:  1/2  milk  and  1/2 
water.     The  formula  for  rectal  feeding  should  be: — 

TJ  Breast-milk      V2  ounce. 

Starch-water     1/2  ounce. 


FEEDING  OF  INFANTS  IN  INCUBATORS.  .     197 

Add  contents  of  1  Fairchild  peptonizing  tube,  and 
inject  this  quantity  with  an  infant's  rectal  syringe.  (See 
illustration,  Fig.  41.)  The  starch-water  is  made  by  tak- 
ing 2  teaspoonfuls  of  ordinary  starch  and  mixing  it 
with  1/2  teacupful  of  warm  water  (not  boiling  water) 
and  making  a  milky  mixture  of  the  same.  This  starch- 
water  should  be  made  fresh  for  each  feeding.  It  is  ad- 
visable to  feed  about  once  every  six  hours  with  the  above 
solution. 

Cleanse  the  rectum  thoroughly  by  washing  with  1/2 
pint  of  lukewarm,  Castile-soap  water  to  remove  all  fasces 
ten  minutes  before  the  nutrient  fluid  (peptonized  milk) 
is  injected. 

PREMATURE    INFANTS    (GRIFFITH). 

Premature  Birth. — A  child  may  be  born  in  the  sev- 
enth or  eighth  month  of  pregnancy,  or  even  earlier,  long 
before  it  is  quite  ready  to  live  outside  of  the  mother's 
body,  and  when  it  weighs  not  more,  perhaps,  than  two 
and  a  half  or  three  pounds.  We  need  not  necessarily 
despair  of  the  life  of  a  baby,  however  unpromising  it 
seems  at  first.  Children  born  at  six  and  a  half  months 
have  grown  up  strong  at  last,  although  it  is  not  often 
they  survive  if  born  before  the  seventh  month.  The 
great  need  of  such  a  baby  is  heat,  and  the  maternity  hos- 
pitals employ  an  apparatus,  called  a  couveuse,  brooder, 
or  incubator,  especially  devised  to  supply  it.  (Fig.  38.) 
For  family  use,  a  couveuse  may  be  bought  at  the  instru- 
ment-makers, or  hired  from  some  of  them.  This  is,  per- 
haps, better,  as  the  apparatus  is  costly.  But  with  an 
increased  degree  of  attention  we  may  get  along  fairly 
well  without  it.  If  a  premature  baby  is  bathed  at  all 
after  birth,  the  temperature  of  the  water  should  be  102° 
F.,  and  the  greatest  care  should  be  taken,  while  drying, 
to  see  that  the  child  is  not  chilled.  It  should  be  made 
very  warm  by  swaddling  it  in  raw  cotton,  head  and  all, 
leaving  only  the  face  exposed,  wrapping  it  about  with  a 


198  ,  INFANT-FEEDING. 

blanket,  and  tying  it  around  with  a  roller  bandage.  Hot 
bottles  should  be  placed  on  each  side  of  it  as  it  lies  thus 
wrapped  up  in  the  bed,  and  fresh  ones  be  substituted  fre- 
quently. A.  very  convenient  method  is  to  place  the  child 
in  a  baby's  bath-tub  half-full  of  raw  cotton  in  which 
numerous  hot  bottles  have  been  concealed.  The  child's 
only  clothing  consists  of  a  diaper  and  a  shirt.  The  room 
should  be  kept  warm,  and  especially  so  when  this  human 
bundle  is  unwrapped  for  its  bath.  After  bathing,  it 
should  be  rubbed  with  swxet  oil  and  be  rolled  up  again 
in  fresh  cotton.  Often  it  is  better  to  omit  all  bathing, 
and  simply  to  rub  with  the  oil. 

These  premature  infants  lose  considerably  more  in 
proportion  to  their  birth-weight  than  babies  at  term.  This 
is  due  to  their  immature  digestive  tract;  also  to  the  fact 
that  they  are  almost  invariably  intensely  jaundiced.  They 
gain  very  slowly,  and,  if  at  the  end  of  two  or  three  weeks 
they  have  reached  their  birth-weight,  they  have  done  un- 
usually well. 

In  some  of  the  babies  the  color  is  poor  from  the  be- 
ginning, and  at  any  time  they  are  especially  liable  to  at- 
tacks of  cyanosis.  For  these  conditions  a  little  slapping 
to  cause  a  good  cry  or  the  administration  of  oxygen  will 
dissipate  the  blueness.  Often  a  few  drops  of  brandy  in 
hot  water  every  two  or  three  hours  will  prevent  further 
trouble.  One  must  be  very  sure,  however,  that  nothing 
has  been  aspirated  into  the  larynx. 

A  great  danger  in  the  care  of  these  babies  is  their 
susceptibility  to  infections.  The  incubator  itself  is  a 
great  germ-carrier,  and  should  be  regularly  disinfected. 
The  weakness  of  the  lungs  and  gastro-enteric  tract  makes 
the  infants  especially  vulnerable.  Unless  the  air  is  fil- 
tered, dirt  is  carried  in  continuously;  consequently  the 
streptococcus,  staphylococcus,  and  pneumococcus  are  al- 
ways present,  seeking  an  avenue  of  entrance.  Through 
the  skin  in  eczematous  spots  or  in  areas  of  irritation;  at 
the  navel;   through  the  eyes,  nose,  mouth,  larynx,  lungs, 


FEEDING  OF  INFANTS  IN  INCUBATORS.  _     199 

stomach,  and  rectum  the  bacteria  can  gain  admission.  To 
prevent  infection  the  most  careful  cleansing  is  always  nec- 
essary, both  of  the  incubator  and  the  baby.  Undoubtedly 
most  of  the  deaths  of  our  cases  could  be  traced  to  this 
source. 

Finally,  in  the  carrying  out  of  the  above  essentials 
in  the  proper  management  of  the' premature  infant,  we 
require  the  most  patient  and  painstaking  attention  on  the 
part  of  the  nurse,  and  upon  her  conscientiousness  depends 
the  chance  of  its  survival. 

Results. — The  statistics  are  taken  from  2314  births 
which  occurred  at  the  Sloane  Maternity  Hospital. 

Tour  hundred  and  ten  of  these  babies  were  prema- 
ture, but  of  these  74  were  still-births,  which  include  mac- 
erated foetus,  and  still-born  babies  of  cases  of  placenta 
prsevia,  accidental  haemorrhage,  eclampsia,  and  the  like, 
leaving  336  for  treatment. 

Among  these  cases  were  a  set  of  triplets,  and  there 
were  18  pairs  of  twins;  85  were  treated  as  infants  at 
term,  and  of  these  4  died, — a  mortality  of  4  1/2  per  cent. ; 
145  were  put  in  cotton,  and  of  these  12  died, — a  mor- 
tality of  8  per  cent.  Some  of  this  class  should  have  been 
placed  in  the  incubator,  but  for  lack  of  room  it  was  im- 
possible;   106  were  incubator  babies. 

These  are  divided  into  two  classes:  1.  Those  that 
died  within  four  days  of  birth.  2.  Those  that  lived 
longer  than  four  days. 

Twenty-nine  of  the  incubator  babies  died  within  four 
days.  All  of  these  but  3  were  more  or  less  asphyxiated 
at  birth ;  9  were  breech  cases,  and  of  these  5  were  difficult 
extractions;  3  after  an  accouchement  force  in  placenta 
prsevia.  The  rest  were  vertex  presentations,  but  of  these 
2  were  forceps  deliveries;  6  were  under  7  months  of 
uterine  gestation;  22  were  between  7  and  8  months  along, 
and  1,  8  1/4  months. 

The  etiology  of  the  premature  labor  was  an  endo- 
metritis in  14;   syphilis  in  2;   albuminuria  in  1;   placenta 


200  INFANT-FEEDING. 

praevia  in  3;  accidental  hemorrhage  in  1;  persistent 
vomiting  in  1;  twin  in  1;  violence  in  1;  and  in  4  the 
labor  was  induced.  The  largest  baby  weighed  5  2/ie 
pounds;  the  smallest  2  7/16  pounds.  Only  5  infants 
lived  over  twenty-four  hours;  24  were  in  such  poor  con- 
dition at  birth  that  they  survived  only  a  few  hours.  In 
16  autopsies  were  held,  and  in  all  of  these  there  were 
marked  atelectasis;  in  7  haemorrhages  of  some  degree, 
either  into  the  brain  or  into  the  serous  membranes;  in 
2  the  foramen  ovale  was  still  patent. 

Seventy-seven  incubator  infants  survived  the  first 
four  days;  51  were  children  of  primiparae,  27  of  whom 
were  out  of  wedlock;  3  infants  were  under  7  months  of 
gestation,  8  were  over  8  months  along;  9  were  breech 
presentations;  1  a  transverse  and  the  rest  vertices;  2 
were  of  triplets  associated  with  albuminuria;  18  were  in 
twin  deliveries,  associated  with  albuminuria  or  hydram- 
nios.  The  cause  of  the  premature  labor  was  endometritis 
in  27;  syphilis  in  4;  phthisis  in  2;  albuminuria  in  7; 
accidental  haemorrhage  in  1;  placenta  prsevia  in  1;  in 
2  the  labor  was  induced  for  albuminuria  and  eclampsia; 
1  was  a  Caesarean  section;  another  an  ectopic  gestation; 
the  cause  of  the  rest  was  unknown.  Seven  were  delivered 
by  forceps;  2  by  a  version;  1  by  accouchement  force;  1 
by  Caesarean  section,  and  the  ectopic  gestation  by  a  lapa- 
rotomy; 12  were  slightly  asphyxiated  at  birth;  9  mod- 
erately so,  and  5  deeply  asphyxiated;  2,  after  one  and 
a  half  hours'  work  of  resuscitation,  were  put  in  the  in- 
cubator head  downward,  and  their  condition  was  so  poor 
that  they  were  expected  soon  to  die,  but  they  left  the 
hospital  gaining  in  weight;  5  weighed  less  than  3  pounds; 
38  between  3  and  4  pounds;  33  between  4  and  5  pounds; 
1  over  5  pounds;  the  average  weight  was  3  12/16  pounds. 
During  their  incubator-life  28  had  one  or  more  attacks 
of  atelectasis.  All  but  10  were  more  or  less  jaundiced. 
The  initial  loss  of  the  infants  was  from  1  to  17  1/2  ounces; 
the  average  was  7  ounces.     These  figures  are  not  quite 


FEEDING  OF  INFANTS  IN  INCUBATORS. 


201 


correct,  as  the  babies  were  weighed  at  different  intervals, 
some  on  the  fifth  day,  some  on  the  seventh  day,  and 
others  not  till  the  fourteenth  day. 


tSRl 


Fig.  38. 


202  INFANT-FEEDING. 

The  period  of  loss  was  from  five  to  twenty-two  days, 
the  average,  eleven  days;  10  lost  steadily  till  death;  one 
baby  was  in  the  incubator  only  three  days,  while  another 
lived  there  eighty-two  days.  The  average  time  was  nine- 
teen days.  Some  were  removed  early  to  make  room  for 
others  who  needed  the  place  more  urgently. 

Only  3  of  the  77  cases  vomited.  The  stools  were 
normal  in  32. 

One  was  discharged  from  the  hospital  as  early  as  the 
eleventh  day,  and  others  also  too  soon  at  their  mothers' 
demand.    One  was  89  days  old;  the  average  was  24  days. 

In  16  diluted  breast-milk  was  supplemented,  at  times, 
with  a  mixture  of  cows'  milk  and  water,  with  Russian 
gelatin  and  lactose.  In  10  a  1,  6,  0.33  modification  was 
used.  In  all  the  rest  diluted  breast-milk  was  relied  upon. 
Twenty-seven  never  nursed  at  the  breast;  of  these,  12 
died.  A  few  nursed  as  early  as  the  third  or  fourth  day 
two  or  three  times  a  day.  Others  not  for  three  weeks, 
and  one  not  till  the  sixty-eighth  day.  Of  the  77,  13  died 
in  the  hospital:  a  mortality  of  16  per  cent.  The  cause  of 
death  was  atelectasis  and  bronchitis  in  7,  acute  asphyxia 
from  a  curd  in  the  larynx  in  1,  syphilitic  pneumonia  in 
1,  cerebral  haemorrhage  in  1,  gastro-enteritis  in  3,  and 
a  patent  foramen  ovale  and  ductus  arteriosus  in  1.  The 
condition  of  3  was  poor  at  the  time  of  discharge,  fair 
in  24,  and  very  good  in  37;  32  were  above  their  birth- 
weights,  and  57  were  gaining  nr  weight.  To  letters 
written  about  January  1,  1900,  no  answer  was  obtained 
from  28.  Thirteen  were  reported  as  having  died,  1  of 
these  lived  fourteen  months,  1  nine  months,  1  four  and 
one-half  months,  3  lived  two  months,  6  lived  six  weeks, 
1  only  a  month.  Five  of  these  died  at  the  Nursery  and 
Child's  Hospital  and  2  died  at  Bellevue  Hospital.  They 
were  bottle-fed,  and  the  probable  cause  of  death  was 
gastro-enteritis.  Twenty-one  were  found  to  be  alive  and 
doing  well.  Some  had  nursed  and  the  others  were  bottle- 
fed.     The  oldest  baby  was  twenty-two  months,  and  al- 


FEEDING  OF  INFANTS  IN  INCUBATOES. 


203 


most  all  were  good,  healthy  children.  One  baby  at  seven 
months  weighed  16  pounds.  It  weighed  4  Vie  pounds 
at  birth,  and  nursed  from  its  mother  after  leaving  the 
hospital.  The  ectopic  and  the  Csesarean  babies  were  in 
beautiful  condition. 


Incubators. 

Tarnier. 

Per 

Cent. 

Charles. 

Per 

Cent. 

Sloane 

Hospital 

Per 

Cent. 

At  the  Sloane 
Hospital,  not 

Counting 

those  which 

Died  in  a  Few 

Hours. 

Per  Cent. 

Saved  at  6    months. 
Saved  at  6J  months. 
Saved  at  7    months. 
Saved  at  7J  months. 
Saved  at  8    months. 

16 
36 

49 

77 
88 

10 
20 
40 

75 

22 

41 
75 

70 

66 
71 
89 
91 

The  incubator  here  described  (see  illustration,  Fig. 
38)  is  the  one  used  at  the  Sloane  Maternity  Hospital. 
There  are  a  great  variety  of  these  incubators,  but  the  one 
made  by  the  Kny-Scheerer  Company  in  this  city  will  an- 
swer all  requirements.  Owing  to  its  expense,  the  manu- 
facturers will  lend  an  incubator  for  a  nominal  sum  per 
month. 

Food  used  in  an  incubator  when  breast-milk  was  not 
obtainable;  baby  gained  in  weight  and  took  diluted  cows' 
milk  after  five  weeks.  Of  goat-milk,  diluted  with  sterile 
water : — 

Goat-milk 1     part; 

Sterile  water 4     parts ; 

Milk-sugar  Va  teaspoonful; 

Peptogenic   y4  measure, 

heated  five  minutes,  1  ounce  was  fed  with  a  medicine- 
dropper  to  a  premature  baby  every  two  and  one-half 
hours,  later  every  two  hours,  with  excellent  results. 


CHAPTER  XXX. 

Aerated  Milk. 

Aeration  of  Milk. — Milk  when  drawn  from  the  cow 
contains  a  certain  amount  of  dissolved  gases.  These  gases 
contain  more  or  less  of  what  is  known  as  animal  odor,  the 
amount  of  this  odor  depending  very  largely  upon  the 
physical  condition  of  the  animal  at  the  time  the  milk  is 
drawn.  Sometimes  the  amount  is  very  slight  and  scarcely 
noticeable;  at  other  times  it  is  so  great  as  to  be  extremely 
offensive.  These  gases  and  the  accompanying  odor  are 
easily  removed  from  the  milk  by  exposure  of  the  milk  to 
the  air  during  the  process  of  cooling,  and  to  this  extent 
aeration  of  the  milk  is  an  advantage.  Various  forms  of 
aerators  and  combined  aerators  and  coolers  have  been 
devised,  many  of  which  are  simple  and  effective,  and  the 
best  results  follow  their  use.  In  order  to  secure  these 
results  by  aeration,  however,  it  is  necessary  that  the  ap- 
paratus used  for  aeration  should  expose  the  milk  thor- 
oughly to  the  air,  should  not  be  cumbersome,  and  should 
be  simple  and  easily  cleaned;  moreover,  the  process  of 
aeration  should  always  take  place  in  the  purest  atmos- 
phere possible. 

Certified  Milk. 

Dr.  IT.  L.  Coit  organized  a  medical  commission  in 
Newark,  1ST.  J.,  which  has  made  agreements  with  the 
dairymen  compelling  them  to  look  after  the  details  per- 
taining to  the  food,  the  selection  of  the  cows,  and — most 
particularly — the  handling  of  the  milk.  All  this  is  under 
the  supervision  of  the  Medical  Commission.  A  veterinary 
surgeon  is  employed  for  the  inspection  of  the  animals. 
In  like  manner  a  chemist  and  bacteriologist  see  that  the 
(204) 


CERTIFIED  MILK.  205 

milk  is  kept  to  the  standard  requirements  of  composition 
and  purity.  The  milk  is  delivered  in  bottles,  which  are 
labeled  "Certified  Milk."  This  plan  has  proved  to  be 
very  successful,  and  certainly  deserves  imitation. 


CHAPTER  XXXI. 

Proprietary  Infant-foods. 

There  have  been  a  great  number  of  infant-foods  and 
seemingly  a  great  variety  placed  upon  the  market  and  ex- 
ploited by  the  makers  as  suitable  for  the  artificial  feeding 
of  infants. 

These  infant-foods  may  be  broadly  classified  under 
two  heads  of  (A)  infant-foods  in  which  cows'  milk  desic- 
cated is  a  constituent,  and  (B)  infant-foods  to  be  used 
with  and  as  adjuncts  to  fresh  cows'  milk. 


Fig.  39. — Feeding-cup,  after  Period  of  Weaning. 


The  infant-foods  of  which  dried  milk  is  a  constituent 
are  made  from  cereals  and  cows'  milk.  The  milk  is  desic- 
cated in  the  process  of  manufacture,  and  these  foods  are 
commonly  known  as  dried-milk  foods,  although  in  this 
class  of  foods  milk-solids  constitute  but  from  one-eighth 
to  one-fourth  the  substance  of  the  foods,  the  balance  con- 
sisting of  matters  derived  from  cereals.  In  some  of  these 
foods  the  starch  of  the  cereals  is  untransformed,  and  they 
(206) 


PROPRIETARY    INFANT-FOODS.  207 

may  be  termed  farinaceous  dried-milk  foods.  In  others 
the  starch  of  the  cereals  has  been  transformed  into  dex- 
trin and  maltose,  and  they  may  be  termed  malted  dried- 
milk  foods. 

All  attempts  to  preserve  whole  cows'  milk  by  evapo- 
rating it  to  dryness  have  been  failures;  the  fat  of  desic- 
cated milk  soon  acquires  a  rancid  flavor,  and  the  caseous 
matter  does  not  properly  dissolve  in  water,  as  the  drying 
process  destroys  its  colloidal  condition.  In  the  dried- 
milk  foods  the  caseous  matter  of  the  cows'  milk  is  inti- 
mately mixed  with  the  other  ingredients,  but  its  colloidal 
condition  has  been  destroyed,  and  it  is  in  the  form  of  fine, 
hard,  granular  particles,  very  sparingly  soluble  in  water. 

The  group  of  infant-foods  used  as  adjuncts  to  cows' 
milk  are  either  farinaceous  foods,  made  from  cereals  and 
consisting  largely  of  unconverted  starch ;  or  malted  foods, 
also  made  from  cereals,  but  having  the  starch  transformed 
into  soluble  maltose  and  dextrin.  As  fresh  cows'  milk  is, 
without  doubt,  the  best  generally  available  material  for 
the  artificial  feeding  of  infants,  the  foods  of  the  latter 
class,  used  for  the  modification  of  fresh  cows'  milk,  are 
more  in  accord  with  physiological  principles  than  are  the 
dried-milk  foods. 

Of  the  large  number  of  infant-foods  that  have  been 
put  on  the  market,  it  is  our  purpose  to  describe  a  few 
commonly  known  foods.  In  order  to  judge  fairly  of  the 
nutritive  value  of  an  infant-food  and  its  resemblance  to 
woman's  milk,  it  is  necessary  to  know  its  composition 
after  its  preparation  for  the  nursing-bottle  according  to 
the  directions  of  its  manufacturer,  and  the  analyses  that 
accompany  the  following  descriptions  are  of  the  foods 
prepared  for  use  for  infants  six  months  of  age  as  per 
directions  on  the  packages. 

The  published  analyses  of  woman's  milk  show  the 
great  variability  of  its  composition,  especially  as  regards 
the  percentages  of  proteids  and  fats.  The  analysis  of 
woman's  milk  used  in  the  following  tables  is  by  Dr.  Luff, 


208  INFANT-FEEDING. 

adopted  as  the  standard  by  Cheadle.  It  agrees  closely 
with  Leeds's  analysis,  excepting  as  to  the  fat,  which  is 
given  by  Luff  as  2.41  per  cent,  and  by  Leeds  as  4.13  per 
cent.;  the  latter  amount  seems  too  large,  as  it  exceeds 
considerably  the  published  averages  of  a  number  of  ob- 
servers. 

nestle' s  FOOD. 

ISTestle's  food  is  a  farinaceous  dried-milk  food  of  Class 
A.  According  to  the  manufacturers,  it  is  made  "from 
the  richest  and  purest  cows'  milk,  the  crust  of  wheaten 
bread,  and  cane-sugar,"  and  is  a  "form  of  modified  milk." 
"JSTo  cows'  milk  is  to  be  added  to  Nestle's  food;  nothing 
but  water,  and  that  water  is  boiled." 

Upon  examination,  unconverted  starch  and  cane- 
sugar  are  found  to  be  its  principal  constituents,  amount- 
ing to  about  70  per  cent,  of  the  whole.  The  directions 
for  preparing  Nestle's  food  for  the  nursing-bottle,  for  in- 
fants six  months  old,  are  to  use  2  level  tablespoonfuls  of 
the  food  to  1/2  pint  of  water;  mix  the  food  with  enough 
warm  water  to  make  a  smooth  paste  that  will  pour,  add 
the  rest  of  the  water  and  boil  in  a  sauce-pan,  stirring 
constantly  until  it  thickens  and  a  milky  foam  appears  on 
the  top. 

Composition  of  Nestle's 

Food,™  when  Prepared 

as  Above.  Woman's  Milk. 

Water   92.76  88.51 

Salts    0.13  0.34 

Proteids    0.81  2.35 

Fat    0.36  2.41 

Starch 1.99 

Cane-sugar 2.57 

Maltose,  dextrin,  etc 0.44 

Milk-sugar    0.84  6.39 

Reaction  alkaline.     Reaction  alkaline. 


1  According  to  Chittenden. 


PROPRIETARY    INFANT-FOODS. 


209 


The  mixture  owes  its  thick  condition  mainly  to  the 
insoluble  starch  present.  The  total  carbohydrates  therein 
(5.84  per  cent.)  are  somewhat  less  than  the  carbohydrate, 
milk-sugar  (6.39  per  cent.),  in  woman's  milk;  it  is  to  be 
noted  that  of  this  amount  1.99  per  cent.,  or  about  one- 
third,  consists  of  insoluble  starch. 

The  fat  is  nearly  one-sixth  and  the  proteids  are  about 
one-third  of  the  amounts  in  woman's  milk,  and  over  one- 
half  of  the  proteids  is  insoluble,  owing  to  the  colloidal 
condition  of  the  milk-casein  having  been  destroyed  by 
drying  during  manufacture. 

horlick's  malted  milk. 
This  is  a  malted  dried-milk  food  of  Class  A,  stated 
on  the  circulars  to  be  composed  of  pure,  rich,  cows'  milk 
combined  with  an  extract  of  malted  grain,  and  not  to  re- 
quire the  addition  of  cows'  milk.  Its  makers  claim  that, 
by  special  treatment  with  their  new  agent,  plant-pepsin, 
the  casein,  or  cheesy  part,  of  the  cows'  milk  is  kept  from 
forming  large  and  irritating  curds  in  the  stomach. 

The  directions  for  preparing  the  food  for  an  infant 
six  to  twelve  months  of  age  are  to  dissolve  4  to  6  tea- 
spoonfuls  in  V2  Pint  of  water.  Composition  when  pre- 
pared by  using  6  teaspoonfuls  of  food  to  1/2  pint  of 
water : — 

Horlick's  Malted  Milk.m  Woman's  Milk. 

Water   92.47  88.51 

Salts    0-29  0-34 

Proteids    L15  2-35 

Fat    °.68  2Al 

Maltose  and  dextrin 4.20 

Milk-sugar I-18  6-39 

Reaction  alkaline.     Reaction  alkaline. 

This  food  is  very  nearly  soluble  in  water,  as  its  prin- 
cipal constituents  are  the  soluble  carbohydrates— maltose, 

69  According  to  Chittenden. 


210  INFANT-FEEDING. 

dextrin,  and  milk-sugar:  The  drying  process  lias  de- 
stroyed the  colloidal  condition  of  the  caseous  matter  of 
the  milk,  and  it  is  in  the  form  of  finely  powdered,  hard 
particles,  sparingly  soluble  in  water. 

The  proteids,  fat,  and  carbohydrates  are  all  less  than 
in  woman's  milk,  the  proteids  being  not  quite  one-half 
and  the  fat  not  quite  one-third  of  the  amounts  in  woman's 
milk.  The  amount  of  milk  employed  must  be  very  small 
in  proportion  to  the  cereal  constituents,  since  the  mixture, 
prepared  as  above,  corresponds  to  a  dilution  of  1  part  of 
good  cows'  milk  with  about  4  parts  of  water. 

MILKINE. 

This  is  a  malted  dried-milk  food  (Class  A).  Its  mak- 
ers state  it  is  a  complete  food  ready  for  immediate  use  by 
the  addition  of  water,  and  the  only  prepared  food  that 
combines  the  nutritive  elements  of  meat,  milk,  and  cereals. 

In  this  malted  dried-milk  food,  beef-extract  is  com- 
bined with  cereal  extractives  and  dried  milk.  Soluble  car- 
bohydrates are  its  principal  constituents,  forming  nearly 
three-fourths  of  the  product.  The  proteids  are  sparingly 
soluble. 

The  directions  for  preparing  milkine  for  an  infant 
three  to  six  months  of  age  are  to  dissolve  1  to  2  dessert- 
spoonfuls of  food  in  a  breakfastcupful  of  water. 

Composition  when  prepared  with  2  dessertspoonfuls 
in  a  breakfastcupful  of  water: — 

Milkine.  Woman's  Milk. 

Water  92.78  88.51 

Salts    0.23  0.34 

Proteids    0.92  2.35 

Fat 0.43  2.41 

Maltose,  dextrin,  etc 4.74 

Milk-sugar 0.90  6.39 

Reaction  alkaline.     Reaction  alkaline. 

The  total  solids  are  hardly  two-thirds  of  the  amount 
in  woman's  milk.     The  fat  especially  is  greatly  deficient, 


PROPRIETARY    INFANT-FOODS.  211 

being  only  about  one-sixth  of  the  amount  in  woman's 
milk,  and  the  proteids  are  but  two-fifths  of  the  amount 
in  woman's  milk. 

A  dilution  of  1  part  of  good  cows'  milk  with  about 
7  parts  of  water  will  contain  about  the  same  amount  of 
milk  as  milkine  prepared  as  above. 

CEREAL    MILK. 

Cereal  milk  is  a  malted  dried-milk  food  (Class  A).  It 
is  stated  by  its  makers  to  be  a  complete  food,  cooked  and 
ready  for  use  with  the  simple  addition  of  water,  and  to 
be  made  from  the  purest  Vermont  dairy-milk,  the  finest 
wheat-gluten  flour,  the  best  barley-malt,  and  milk-sugar. 

Cereal  milk  in  general  appearance  very  much  resem- 
bles the  other  malted  dried-milk  foods,  but  it  contains  a 
much  greater  percentage  of  milk-sugar,  showing  that  this 
substance  is  used  in  its  manufacture,  as  claimed. 

The  directions  for  preparing  it  for  use  are  to  mix  1 
teaspoonful  of  cereal  milk  in  a  teacupful  of  hot  water 
for  infants  under  three  months  of  age  or  for  a  very  deli- 
cate child.  For  older  and  stronger  children  1  to  2  tea- 
spoonfuls  of  food  are  to  be  used  to  each  cupful  of  water. 
Composition  when  prepared  by  using  2  heaping  teaspoon- 
fuls  of  food  to  a  teacupful  of  water: — 

Cereal  Milk.  Woman's  Milk. 

Water  92.52  88.51 

Salts    0.16  0.34 

Proteids    0.69  2.35 

Tat    0.30  2.41 

Maltose,  dextrin,  etc 4.73 

Milk-sugar 1.60  6.39 

Eeaction  alkaline.     Reaction  alkaline. 

The  total  of  soluble  carbohydrates  as  above  is  prac- 
tically the  same  as  in  woman's  milk;  the  amount  of  pro- 
teids is  less  than  one-third  the  amount  in  woman's  milk, 
and  about  one-half  is  insoluble  in  water.  The  amount  of 
fat  is  one-eighth  the  amount  in  woman's  milk.    The  small 


212  INFANT-FEEDING. 

amount  of  fat  indicates  that  the  cereal  extractives  and 
milk-sugar  make  up  the  bulk  of  the  solids  of  this  food, 
and  that  a  dilution  of  1  part  of  good  cows'  milk  with 
11  parts  of  water  would  be  the  counterpart  of  the  above 
mixture  as  to  the  amount  of  milk  therein. 

wampole's  milk-food. 

Wampole's  milk-food  is  a  malted  dried-milk  food 
(Class  A).  Its  makers  state  that  it  is  made  from  malted 
cereals,  beef,  and  milk,  and  when  mixed  with  warm  water 
it  is  immediately  ready  for  use;  no  other  preparation 
necessary. 

This  dried-milk  food  is  very  nearly  soluble  in  water, 
owing  to  the  soluble  carbohydrates  being  so  large  a  con- 
stituent. A  little  less  than  one-half  of  the  proteids  is 
insoluble  in  water.  A  small  amount  of  beef-extract  has 
been  combined  with  the  cereal  extractives  and  dried  milk. 

To  prepare  it  for  an  infant  six  months  to  one  year  of 
age,  the  directions  are  to  dissolve  4  to  6  teaspoonfuls  of 
the  food  in  6  ounces  of  hot  water.  Composition  when 
prepared  by   dissolving   6   teaspoonfuls  in   6   ounces  of 

water: — 

Wampole's  Milk-food.        Woman's  Milk. 

Water  88.59  88.51 

Salts    0.46  0.34 

Proteids   1.58  2.35 

Fat    0.73  2.41 

Maltose,  dextrin,  etc .  7.65 

Milk-sugar 0.99  6.39 

Reaction  alkaline.     Reaction  alkaline. 

Compared  with  woman's  milk  it  is  seen  that  the  car- 
bohydrates are  considerably  in  excess,  and  the  proteids 
and  fat  are  deficient,  the  fat  especially,  it  being  less  than 
one-third  the  amount  in  woman's  milk. 

One  part  of  good  cows'  milk  diluted  with  about  3  1/2 
parts  of  water  would  be  analogous  to  the  dilution  of  milk 
in  "Wampole's  milk-food  prepared  as  above. 


PROPRIETARY   INFANT-FOODS.  213 

IMPERIAL    GRANUM. 

Imperial  granum  is  a  farinaceous  food  to  be  used  as 
an  adjunct  to  cows'  milk  (Class  B). 

Its  makers  state  that  it  is  a  solid  extract  derived  from 
very  superior  growths  of  wheat,  nothing  more.  It  appears 
to  be  made  as  claimed  from  wheaten  flour  and  to  be  mainly 
composed  of  torrefied  starch. 

Tor  an  infant  six  months  of  age  it  is  to  be  prepared 
by  cooking  3  1/2  teaspoonfuls  of  food  in  21  ounces  of 
water  and  20  ounces  of  milk. 

Composition  when  prepared  as  above: — 

Imperial  Granum.00         Woman's  Milk. 

Water  91.53  88.51 

Salts    0.34  0.34 

Proteids    2.15  2.35 

Fat 1-54  2.41 

Starch     1.22 

Maltose,  dextrin,  etc 0.58 

Milk-sugar     2.71  6.39 

Reaction  alkaline.     Reaction  alkaline. 

The  total  of  solids  contained  is  one-quarter  less  than 
in  woman's  milk;  the  carbohydrates  are  nearly  one-third 
less  than  the  amount  in  woman's  milk  and  it  should  be 
observed  that  1.22  per  cent.,  or  about  one-fourth  of  them, 
consist  of  starch;  there  is  only  a  slight  deficiency  in  the 
amount  of  proteids,  but  a  considerable  deficiency  in  the 
amount  of  fat.  By  using  more  milk  or  milk  and  cream 
and  less  water  than  above  employed  the  percentages  of 
fat,  proteids,  and  soluble  carbohydrates  would  be  in- 
creased. 

Its  very  large  proportion  of  starch  forms  the  principal 
objection  to  this  food. 

The  presence  of  unconverted  starch  causes  the  thick 
condition  of  the  mixture. 


80  According  to  Chittenden. 


214  INFANT-FEEDING. 

eskay's   ALBUMENIZED   FOOD. 

This  food  is  to  be  prepared  with  cows'  milk  (Class  B). 
Its  makers  state,  in  recommending  their  product,  that  it 
contains  the  more  easily  digested  cereals,  combined  with 
egg-albumin. 

Eskay's  albumenized  food  consists  largely  (about  88 
per  cent.)  of  carbohydrates;  the  soluble  carbohydrates, 
mostly  milk-sugar,  are  about  50  per  cent.,  and  the  insol- 
uble carbohydrates,  mostly  starch,  are  a  little  less  than  40 
per  cent.  On  account  of  this  proportion  of  starchy  matter 
in  the  dry  food,  it  may  be  termed  farinaceous.  The  mak- 
ers, however,  claim  that  in  the  process  of  manufacture  the 
starch-granules  are  almost  entirely  disintegrated,  and  when 
the  food  is  prepared  with  milk  according  to  directions  the 
percentage  is  said  to  be  not  over  1  1/2  to  2  per  cent.  An 
analysis  of  the  dry  food  shows  that  it  contains  about  9 
per  cent,  of  proteid  matter,  but  when  prepared  accord- 
ing to  the  six  months'  formula  it  analyzes  about  2.55  per 
cent. 

The  egg-albumin  is  said  to  be  first  combined  with 
sugar  of  milk  in  such  a  thorough  manner  that  the  parti- 
cles are  finely  subdivided,  and  no  firm,  hard  coagulum  can 
therefore  take  place  in  the  stomach.  The  particles  retain 
their  identity,  and  do  not  coalesce;  so  that  in  the  finished 
preparation  the  egg-albumin  is  suspended  throughout  the 
whole  mixture  in  very  fine  particles,  which  are  easily  di- 
gested, because  the  gastric  juice  acts  by  contact,  and,  the 
smaller  the  particles,  the  greater  the  effect  of  the  gastric 
juice.  No  claims  are  made  by  the  manufacturers  for  its 
solubility,  but  for  its  ease  of  digestion  and  its  nutritive, 
value. 

The  directions  for  preparing  it  for  an  infant  six  months 
of  age  are  to  take: — 

2y2  tablespoonfuls  of  food. 

1       pint  of  hot  water. 

1       pint  of  rich  cows'  milk. 


PROPRIETARY    INFANT-FOODS.  215 

When  prepared  as  above,  using  rich  cows'  milk,  con- 
taining about  6  per  cent,  of  fat,  their  analysis  shows  that 
it  contains: — 

Eskay's  Albumenizcd 

Food.  Woman's  Milk. 

Fat    2.96  2.41 

Proteids    2.55  2.35 

Carbohydrates    6.13  6.39 

Milk-sugar     5.07 

Insoluble  carbohydrates   1.06 

Reaction  alkaline.     Reaction  alkaline. 

mellin's  FOOD. 

Mellin's  food  is  a  malted  cereal  food  (Class  B).  This 
food  is  stated  by  its  makers  to  be  a  soluble  dry  extract 
from  wheat  and  malt,  for  the  modification  of  fresh  cows' 
milk. 

The  carbohydrates  therein  are  in  the  form  of  dextrin 
and  maltose,  and  constitute  about  80  per  cent,  of  the  food; 
the  proteids  amount  to  about  10  per  cent.,  and  are  derived 
from  the  cereals.  Mellin's  food  is  almost  completely  sol- 
uble in  water.  It  is  especially  noticeable  that  this  food 
does  not  contain  any  starch. 

The  directions  for  preparing  this  food  for  use  for  in- 
fants six  months  of  age  and  over  are  to  dissolve  2  heaping 
tablespoonfuls  of  food  in  1/4  pint  of  hot  water  and  3/4 
pint  of  cows'  milk. 

Composition  when  prepared  as  above: — 

Mellin's  Food.81         Woman's  Millc. 

Water  88.00  88.51 

Salts    0.47  0.34 

Proteids    2.62  2.35 

Pat    2.89  2.41 

Maltose,  dextrin,  etc 2.73 

Milk-sugar     3.25  6.39 

Reaction  alkaline.     Reaction  alkaline. 


According  to  Chittenden. 


21G 


INFANT-FEEDING. 


In  total  solids  this  food  differs  but  slightly  from 
woman's  milk,  and  in  the  various  constituents  its  simili- 
tude to  woman's  milk  is  remarkably  close.  Of  the  car- 
bohydrates the  maltose  and  dextrin  are  a  little  less  in 
amount  than  the  milk-sugar,  and  the  total  carbohydrates 
(5.98  per  cent.)  are  only  slightly  less  than  the  amount 
in  woman's  milk. 

The  manufacturers  of  Mellin's  food  present  many 
formulas  for  preparing  the  food  for  use  to  meet  various 
indications.  The  following  formulas  are  given  with  the 
analyses  of  the  respective  milk-modifications: — 


Formulae  and  Analyses  for  Preparing  Mellin's  Food. 


For  Infants  about  Tioo  Months  Old. 


Mellin's  food,  6  teaspoon- 

fuls   (level). 
Milk,  6y3  fluidounces. 
Water,  9%  fluidounces. 


Gives  this 
composition : 


f  Water  93.40 

Salts    0.35 

Proteids    1.69 

Fat    1.53 

Carbohydrates    (no 

starch)    3.03 


Low  Proteids. 


Mellin's    food,    2    table-  1 
spoonfuls   (heaping). 

Cream,    1%    tablespoon 
fuls. 

Milk,  4  fluidounces. 

Water,  12  fluidounces. 


Gives  this 
composition: 


f  Water  91.50 

Salts    0.37 

Proteids    1.45 

Fat    2.50 

Carbohydrates    (no 
starch)    4.18 


High  Fat  and  Low  Proteids. 


Mellin's    food,    3    table- 
spoonfuls   (heaping.) 
Milk,  4  fluidounces. 
Cream,  2  tablespoonfuls. 
Water,  12  fluidounces. 


Gives  this 
composition: 


f  Water   89.36 

Salts    0.45 

Proteids    1.65 

Fat    3.00 

Carbohydrates    (no 

starch)    5.54 


PROPRIETARY   INFANT-FOODS.  -  217 

PEPTOGENIC    MILK-POWDER. 

This  product  is  stated  by  its  makers  to  be  an  article 
containing  milk-sugar  and  a  digestive  ferment  capable  of 
acting  on  casein,  offered  for  the  preparation  of  an  arti- 
ficial infant-food.  McGill  states :  "It  is  not,  in  the  strict 
sense,  a  food.  Its  professed  object  is  so  to  change  the 
composition  of  cows'  milk  as  to  render  this  comparable 
to  human  milk.  This  it  seeks  to  do  by  introducing  milk- 
sugar  and  small  quantities  of  albuminoids."  According 
to  McGill's  analysis,  it  is  composed  almost  entirely  of 
milk-sugar  (96.60  per  cent.). 

The  following  analysis  is  by  Leeds,  and  is  taken  from 
a  circular  of  the  makers. 

Composition  of  "humanized  milk"  prepared  as  di- 
rected, using  4  measures  of  peptogenic  milk-powder  with 
x/2  pint  of  milk,  1/2  pint  of  water,  and  4  tablespoonfuls 

of  cream: — - 

Humanized  Milk.  Woman's  Millc. 

Water  86.20  88.51 

Ash    0.30  0.34 

Proteids    2.00  2.35 

Fat    4.50  2.41 

Milk-sugar 7.00  6.39 

Reaction  alkaline.     Reaction  alkaline. 

Chittenden's  analysis -of  this  "humanized  milk"  is  al- 
most identical  with  the  above. 

The  proteids  of  the  cows'  milk  undergo  a  change  in 
the  peptonizing  process,  being  converted  chiefly  into  par- 
tial peptones,  and  in  this  form  they  cannot  be  said  to  re- 
semble the  proteids  of  woman's  milk,  which  have  not  been 
acted  upon  by  a  proteolytic  ferment. 


CHAPTER  XXXII. 

Pbofessob  Gaebtnee  Mothee-milk. 

'  Seveeal  years  ago  the  author  was  persuaded  to  use 
Gaertner  milk  ou  a  series  of  cases.  The  milk  was  sold 
in  tin  cans.  The  manufacturers  would  not  take  the  ad- 
vice given  them:  to  use  fresh  milk  and  deliver  the  milk 
in  clean  bottles  daily.  The  author  feels  sorry  to  state 
that  such  food  as  "milk  sealed  in  tin  cans"  cannot  be 
recommended  for  healthy,  and  certainly  not  for  sick,  in- 
fants. 

In  a  paper  entitled  "The  Clinical  Value  and  Chem- 
ical Results"  the  author  published  a  paper  in  the  Med- 
ical Record,  December  11,  1897.  This  new  food  has  now 
been  used  about  five  years  in  Europe,  and  is  the  outcome 
of  the  scientific  endeavors  of  Professor  Gaertner,  of  the 
University  of  Vienna.  The  first  paper  was  published  by 
Gaertner  in  the  Therapeutische  Wochenschrift,  May  5, 
1895. 

A  few  months  before,  January,  1895,  Gaertner,  in 
an  address  before  the  Vienna  Scientific  Society,  explained 
the  mode  of  preparation  and  the  results  obtained  with 
his  new  modification  of  cows'  milk,  for  such  the  mother- 
milk  of  Gaertner  really  is.  Professor  Gaertner,  in  the 
preparation  of  his  food,  has  aimed  to  overcome  what  has 
been  the  great  difficulty  in  infant-feeding — namely:  to 
reduce  the  excess  of  casein  by  a  scientific  process  without 
the  addition  of  chemicals. 

To  achieve  this  result  he  employs  a  machine  called  a 
separator  or  Pfannhaiiser  centrifuge,  which  makes  four 
thousand  or  eight  thousand  revolutions  per  minute.  The 
apparatus  consists  essentially  of  a  drum  of  steel,  which 
revolves  on  its  axis.  This  drum  is  filled  with  equal  parts 
(218) 


GAERTNER  MOTHER-MILK.  219 

of  fresh  cows'  milk  and  sterilized  water.  The  mixture 
contains  approximately  the  same  amount  of  casein  as  hu- 
man milk,  for  cows'  milk  undiluted  contains  about  twice  as 
much  casein  as  human  milk.  The  mixture  is  next  poured 
into  the  centrifuge  and  the  speed  of  the  drum  is  carefully 
regulated,  so  as  to  separate  the  mixture  contained  therein 
into  (1)  a  creamy  (fatty)  milk  and  (2)  a  skimmed  milk. 
The  two  portions  so  separated  are  then  led  off  separately 
by  suitable  openings  in  the  centrifuge. 

The  analysis  of  each  of  these  portions  shows  that  the 
creamy  milk  has  the  same  quantity  of  fat  as  is  found  in 
human  milk,  while  about  2  per  cent,  of  the  casein  is  con- 
tained in  the  skim-milk,  and  the  remainder,  about  1.7  per 
cent.,  remains  in  the  creamy  milk.  The  chemical  com- 
position of  fat  milk  is  shown  in  the  following  table: — 

Proteid.  Fat.  Sugar.  Ash. 

Fat  milk  1.76  3-3.5        2.5  0.35 

Human  milk    1.03  3.5         7.03  0.21 

Cows'  milk  diluted  with  one- 
half  water    1.76  1.6        2.5  0.35 

If,  now,  3  or  4  grammes  of  milk-sugar  be  added  to 
every  100  cubic  centimetres  of  fat  milk,  the  percentage 
of  sugar  is  brought  up  to  the  level  of  sugar  in  human 
milk.  This  addition  is  made  before  sterilizing.  The  fat 
milk  has  the  advantage  over  the  diluted  milk  of  having 
"a  higher  percentage  of  fat";  it  also  curdles  more  slowly 
than  diluted  milk  and  the  curd  forms  a  more  flocculerit 
precipitate. 

According  to  Escherich,  the  following  amounts  should 
be  used  at  different  ages  of  infancy,  feeding  every  two  to 
four  hours: — 


Infants  under  2  weeks 

500  c.cms. 

(i7y2 

I) 

in  9  feedings 

Infants  3  to  4  weeks    . 

750  c.cms. 

(26 

I) 

in  8  feedings 

Infants  4  to  8  weeks   . 

. .   1,000  c.cms. 

(35 

5) 

in  8  feedings 

Infants  3  to  4  months 

. .   1,250  c.cms. 

(42 

5) 

in  8  feedings 

Infants  5  to  6  months 

. .   1,500  c.cms. 

(50 

5) 

in  7  feedings 

220  INFANT-FEEDING. 

Esclierich  gives  in  detail  his  experience  in  feeding 
with  fat  milk  fifty  infants  in  a  hospital,  including  rickety- 
and  tuberculous  children.  He  has  certainly  met  with 
marked  success.  Some  cases  have  been  under  observation 
for  six  months.  His  article  is  published  in  extenso  in 
Mitteilungen  des  Vereins  der  Aerzie  in  Steiermarh,  ~No. 
1,  1895. 

Baginsky62  mentions  Gaertner  milk  as  a  new  form 
of  food  introduced.  In  our  country  Jacobi63  states  that 
Gaertner  milk  is  applicable  to  the  majority  of  infants  who 
require  cows'  milk  appropriately  prepared. 

A  few  years  ago  I  proposed  to  test  the  efficacy  of 
Gaertner  milk.  With  this  in  view  I  subjected  the  milk 
to  a  very  rigid  test,  inasmuch  as  the  time  chosen,  from 
June  to  October,  was  the  heated  term,  which  is  the  worst 
for  milk  digestion,  and  the  hygienic  conditions  of  the 
infants  were  those  found  in  the  average  tenement-house, 
too  well  known  to  need  description. 

The  guides  for  ascertaining  the  degree  of  assimilation 
were  the  following  factors: — 

1.  The  child's  general  condition,  as  manifested  by  its 
appearance,  appetite,  and  sleep. 

2.  The  presence  or  absence  of  gastro-enteric  disturb- 
ances, such  as  vomiting,  colic,  restlessness. 

3.  The  condition  of  the  stools,  constipation  or  diar- 
rhoea, the  number  of  stools  in  twenty-four  hours. 

4.  The  gain  in  weight;    weekly  observations. 

The  nurses  or  mothers  were  instructed  to  note  the 
amount  of  food  taken  and  the  number  of  stools  in  twenty- 
four  hours. 

We  submitted  the  stools  passed  in  twenty-four  hours 
to  Mr.  Herman  Poole,  our  chemist,  whose  chemical  re- 


62  "Lehrbueh   der   Kinderkrankheiten,"    fifth   edition,   pages    35 
and  36. 

63  "Therapeutics  of  Infancy  and  Childhood,"  page  508. 


BACKHAULS   MILK.  221 

port  is  of  interest.64  We  tried  to  ascertain  how  much 
proteids,  fat,  sugar,  and  salts  were  taken,  how  much 
absorbed,  and  how  much  was  voided  in  the  faeces  with- 
out having  taken  part  in  metabolism. 

Backhaus's  Milk.65 

.  The  following  method  is  employed  in  the  production 
of  this  food.  The  milk  from  different  breeds  of  cows  is 
mixed  and  passed  through  a  centrifuge,  to  separate  the 
cream  from  the  milk  and  to  remove  any  impurities  that 
might  have  gained  access  to  the  milk,  notwithstanding 
the  great  care  used  in  handling.  Three  grades  are  pro- 
duced: two  for  infants,  the  third  representing  full  milk 
in  its  composition.  After  separating  it  from  the  cream 
the  milk  is  exposed  to  the  action  of  a  mixture  of  rennet, 
trypsin,  and  sodium  carbonate,  which  are  combined  in 
such  proportions  that  the  trypsin  will  have  converted  at 
the  end  of  thirty  minutes  30  per  cent,  of  the  casein  into 
soluble  albumin.  By  this  time  the  action  of  the  rennet 
coagulates  the  balance  of  the  casein  and  thus  arrests  the 
action  of  the  trypsin.  The  temperature  of  the  mixture 
is  now  raised  to  80°  C.  (176°  F.)  by  the  introduction  of 
steam  into  it.  At  this  temperature  it  is  kept  for  five 
minutes.  At  the  end  of  this  time  it  is  strained  through 
cloths  and  mixed  with  half  its  volume  of  water,  one- 
fourth  its  volume  of  cream,  and  the  necessary  amount  of 
sugar  of  milk.  It  is  finally  put  up  in  bottles  holding  125 
grammes  (about  4  ounces)  and  sterilized. 

The  second  grade,  for  older  children,  is  obtained  by 
mixing  equal  parts  of  milk  and  water  with  half  the  quan- 
tity of  cream  and  with  milk-sugar.  This  is  put  up  in 
quantities  of  200  grammes  (about  6  1/2  ounces). 


64  Those  interested  are  referred  to  my  paper,  entitled  "Gaertner 
Milk,"  containing  an  elaborate  chemical  report  by  Professor  Poole: 
New  York  Medical  Record,  December  11,  1897. 

G5Archiv  fur  Kinderheilkunde,  B.  26,  H.  5  and  6. 


222  INFANT-FEEDING. 

The  third  grade,  in  bottles  holding  300  grammes 
(about  10  ounces),  represents  cows'  milk  in  composition, 
modified  by  the  above-mentioned  process.  The  composi- 
tion of  the  three  grades  is  given  as  follows: — 

Fat   3.1  3.2  3.3 

Sugar  of  milk 6.0  5.4  4.8 

Casein 0.6  1.8  3.0    , 

Albumin    1.0  0.3  0.5 

Ash     0.4  0.4  0.7 

The  milk  has  been  tried  at  the  Wiener  allgemeine 
Poliklinik  by  Friihwald  in  a  series  of  twenty  cases,  the 
histories  of  which  are  given  by  the  author.  With  the  ex- 
ception of  six,  these  children  have  been  under  observation 
for  more  than  two  months.  When  first  seen  the  children 
were  all  suffering  from  different  forms  of  digestive  dis- 
turbances, and  from  malnutrition;  some  were  suffering 
from  severe  marasmus,  and. most  of  them  passed  through 
some  other  disease  while  they  were  under  observation. 
Three  of  the  infants  took  the  breast  in  addition  to  the 
Backhaus  milk  for  periods  of  two  and  three  weeks,  when 
they,  too,  had  to  be  put  on  the  artificial  milk  entirely. 
The  children  took  about  six  bottles  of  ]STo.  1  up  to  four 
weeks,  seven  to  eight  to  the  end  of  the  second  month. 
From  the  middle  of  the  third  month  the  second  degree 
was  gradually  substituted,  while  No.  3  was  used  only  in 
the  case  of  an  older  child.  A  daily  gain  was  observed 
of  from  18  to  30  grammes  (about  V2  to  1  ounce).  In 
private  practice  and  in  healthy  children  a  gain  of  50 
grammes  (about  1 1/2  ounces)  not  rarely  happens.  The 
milk  keeps  well. 

Lahmann's  Vegetable-milk. 

In  Europe,  and  recently  also  in  our  country,  the  feed- 
ing of  infants  has  been  enriched  with  a  new  product; 
thus,  Dr.  Lahmann  believes  that  the  great  panacea  is 
feeding  infants  with  milk  which  he  designates  as  "vege- 


lahmann's  vegetable-milk.  223 

table-milk."  It  resembles  a  thick  jelly,  and  is  made  by 
Hewwel  &  Veithen,  Cologne.  His  theory  consists,  in 
brief,  in  substituting  nuts  and  almonds,  which  are  rich 
in  albumin  and  fat,  instead  of  cereals  to  dilute  milk,  his 
idea  being  that  an  emulsion,  which  is  digestible  and  sup- 
posed to  be  rich  in  albumin,  is  doubtless  better  than  pure 
water  or  a  thin  starch-paste.  In  order  to  add  food-salts, 
which  are  not  supplied  by  this  means,  he  extracted  them 
from  leaf  vegetables,  which  are  rich  in  food-salts,  and 
added  some  sugar-syrup.  In  this  manner  he  claims  to 
have  made  a  preparation  which  he  states  is  chemically 
equal  to  human  milk,  and  full  of  nutritive  value.  His 
idea  is  that  the  interposition  of  plant-albumin  (conglutin) 
particles,  which  coagulate  with  difficulty  between  the 
coagulating  casein  masses,  would  increase  their  digesti- 
bility by  breaking  them  up,  and  that  the  digestion  of  the 
plant-albumin  and  oil,  as  well  as  of  the  sugar  and  food- 
salts,  would  present  no  difficulty. 

Stutzer,  of  the  University  of  Bonn,  reports  thus: 
The  vegetable-milk  is  distinguished  from  children's  food 
by  the  absence  of  starchy  substances.  In  common  with 
Biedert's  cream-mixture,  the  vegetable-milk  contains  con- 
siderable quantities  of  fat  in  an  emulsified  condition.  It 
differs  from  the  cream-mixture  in  the  way  it  is  prepared, 
and  in  its  other  qualities. 

Chemical  Analysis. 

Fat 34.72  per  cent. 

Plant-casein   and   similar   nitrogenous   con- 
stituents      12.00  per  cent. 

Sugar  and  plant-dextrin 31.02  per  cent. 

Salts    1.64  per  cent. 

Water    20.62  per  cent. 

My  own  personal  experience  has  been  rather  favor- 
able with  the  use  of  the  vegetable-milk,  inasmuch  as  an 
emulsion  of  almonds  and  nuts  was  used  to  dilute  the  curd 
of  cows'  milk.     Thus,  equal  parts  of  vegetable-milk  with 


224  INFANT-FEEDING. 

cows'  milk  were  taken  by  an  infant  for  several  months, 
and  it  was  very  well  assimilated.  Not  only  did  the  child 
gain  in  weight,  bnt  the  bowels  were  in  a  fair  condition, 
and  the  infant  remained  strong.  My  experience,  how- 
ever, is  too  limited  as  yet  to  give  a  positive  opinion. 

Condensed  Milk  ok  Condensed  Cream. 

Hundreds  of  infants  are  fed  with  condensed  milk. 
This  has  its  reason: — 

First.  The  readiness  with  which  condensed  milk  is 
obtained. 

Second.  The  great  cheapness  of  this  article. 

Third.  The  ease  with  which  the  feeding-mixture  can 
be  prepared. 

Jacobi  says  that  some  manufacturers  use  pure  cows' 
milk ;  others  find  it  in  accordance  with  the  health  of  their 
bank-accounts  to  use  skimmed  milk. 

Quantity  of  Sugar  in  Condensed  Milk. — Milk  sold  in 
our  city  for  immediate  use  contains  about  12  to  15  per 
cent,  of  sugar.  Milk  to  be  kept  for  an  indefinite  time 
contains  as  much  as  50  per  cent,  of  sugar.  These  varia- 
tions show  how  serious  it  is  to  use  the  same  quantity 
of  condensed  milk  all  the  time  and  from  different 
sources  with  such  an  enormous  variation  in  the  quantity 
of  sugar. 

Kehrer — quoted  by  Jacobi — states,  regarding  it,  that 
it  increases  the  formation  of  lactic  acid.  Fleischman 
states  that  it  gives  rise  to  thrush  and  diarrhoea;  Daly, 
that  it  fattens  them  (?),  but  gives  rise  to  rachitis. 

The  worst  specimens  of  rachitis  and  spinal  rickets  are 
seen  in  my  clinic  in  condensed-milk  babies.  Our  medical 
literature  reports  many  cases  of  apparent  health  in  infants 
fed  on  condensed  milk.  It  has  led  Dessau,  with  a  large 
experience  with  infants,  to  mention  such  a  method,  al- 


CONDENSED  MILK  OR  CONDENSED  CREAM.      225 

though  he  advocates  cows'  milk,  properly  modified,  for 
continued  use.66 

In  traveling,  when  good  fresh  cows'  milk  cannot  be 
obtained,  then  I  permit  the  use  of  condensed  milk,  but 
for  a  few  days  or  for  a  week  only,  as  on  the  ocean  steamer, 
where  cows'  milk  cannot  be  had. 

My  experience  among  hundreds  of  children  seen  in 
my  Children's  Service  at  the  German  Poliklinik  and  also 
at  the  service  at  the  West-Side  German  Dispensary  dur- 
ing these  last  ten  years  has  been  that  children  so  fed  have 
rickets;  that  they  are  predisposed  to  the  infectious  dis- 
orders; that  they  have  less  resistance  and  far  less  vitality, 
especially  in  combating  such  diseases  as  pneumonia  or 
diphtheria;  that  they  have  tendencies  to  hernias  and  de- 
formities, owing  to  the  softer  condition  of  their  muscles 
and  bones;  that  they  invariably  suffer  with  constipation, 
alternating  with  diarrhoea;  that  their  dentition  is  delayed, 
compared  with  other  methods  of  hand-feeding.  Thus 
summing  it  up,  I  cannot  approve  of  this  method  at  all. 
Condensed  cream  will  be  lauded  by  the  mother  whose 
baby  is  well,  and  again  the  same  food  will  be  con- 
demned by  the  mother  of  an  infant  whose  rickety  head, 
bones,  and  muscles  are  founded  on  an  impoverished  diet 
of  condensed  milk.  We  can  account  for  the  rickety  child, 
but  we  cannot  account  for  the  healthy  one  on  the  same 
food. 

The  directions  on  the  tin  of  the  Anglo-Swiss  Con- 
densed Milk  Company's  Milkmaid  Brand  of  condensed 
milk  are,  for  newborn  infants,  add  14  parts  of  water; 
as  the  child  grows  older,  gradually  use  less  water,  but 
never  less  than  7  parts. 

The  analyses  of  all  these  condensed  milks  are  of  the 
milk  diluted  with  both  7  parts  and  14  parts  of  water — 
the  two  extremes. 


66  See  my  paper  on  infant-feeding  (read  before  the  Society  for 
Medical  Progress,  April  11,  1896),  published  in  extenso  in  Pediatrics 
for  July  15,  1896. 


226  INFANT-FEEDING. 

Gail-Borden  Eagle 
Milkmaid  Brand.  Brand. 

With  7  Parts  With  14  Parts  With  7  Parts  With  14  Parts 
Water.  Water.  Water.  Water. 

Water   88.18  93.59  89.10  94.09 

Ash    0.36  0.19  0.29  0.16 

Proteids    1.50  0.82  1.31  0.71 

Fat    1.70  0.92  1.18  0.64 

Cane-sugar    6.00  3.25  6.59  3.57 

Milk-sugar 2.26  1.23  1.53  0.83 

Nestle's  Swiss  Milk. 

WiWa7te?rartS         WiWater.artS    Woman's  Milk. 

Water 87.95  93.46  88.51 

Ash 0.25  0.14  0.34 

Proteids     1.51  0.82  2.35 

Fat   2.14                      1.16  2.41 

Cane-sugar   5.81  3.15 

Milk-sugar    2.34                      1.27  6.39 

The  foregoing  brands  of  condensed  milks  are  consid- 
ered to  be  among  the  best  upon  the  market. 

Cocoa. 

Dr.  H.  Cohn,67  in  describing  the  chemical  value  of 
cocoa  as  nourishment,  states  his  belief  that  it  is  over- 
rated, and  denies  the  value  of  the  same.  He  bases  his 
statement  on  the  poor  method  of  assimilation,  owing  to 
the  large  quantity  of  fat  which  could  be  removed  by 
chemical  process.  Cocoa  also  contains  5.5  per  cent,  of 
tannic  acid.  Besides,  the  albuminoids  are  converted,  by 
the  process  of  roasting,  into  a  very  indigestible  product. 
About  the  tannic  acid,  he  says  that  it  precipitates  the 
digestive  ferments,  and  unites  with  the  albuminoids  into 
insoluble  compounds,  causing  the  constipating  factor. 
According  to  his  experiments,  only  one-half  of  the  16.6 
per  cent,  of  the  albuminoids  are  absorbed,  and,  in  order 
to  give  the  human  body  enough  cocoa  to  have  a  sufficient 
quantity  of  proteids,  it  would  be  necessary  to  feed  at  least 


Zeitschrift  fur  physiologische  Chemie,  xx,  1,  2. 


CHOCOLATE,  ICE-CREAM,  AND  WATER-ICES.  227 

somewhat  over  2  pounds  daily,  provided  cocoa  alone  was 
given  for  nourishment. 

« 

Chocolate. 

Chocolate  contains  about  45  per  cent,  of  cane-sugar, 
but  no  dextrose  or  lsevulose.  The  remainder  consists  of 
cocoa-powder.  Invert-sugar,  or  a  mixture  of  glucose  and 
albumin,  is  largely  used  in  the  preparation  of  uncrystal- 
lized  sweets,  such  as  the  creamy  matter  in  the  interior  of 
chocolate  drops.  The  coloring  of  sweets  is  derived  either 
from  burnt  sugar  or  from  one  of  the  aniline  dyes,  most 
commonly  eosin.  Cochineal  is  also  a  favorite  colorer.  It 
is  interesting  to  know  that  these  dyes  may  be  excreted 
in  the  urine  almost  unchanged,  and  cases  are  on  record 
where  patients  were  supposed  to  be  passing  blood  when 
they  had  merely  been  sucking  red  sweets.  There  is  no 
reason  to  suppose,  however,  that  such  substances  are  harm- 
ful to  life.68  When  there  is  a  tendency  to  loose  bowels, 
especially  after  the  second  summer,  cocoa  and  chocolate 
should  be  added  to  the  dietary.  It  is  to  be  added  to  milk 
and  thoroughly  boiled.  One  cocoa  feeding  per  day  is 
usually  enough.  One  teaspoonful  of  cocoa  to  a  cup  of 
milk,  the  latter  to  be  thoroughly  boiled,  is  the  usual  quan- 
tity used.  Several  formulae  for  making  chocolate  will  be 
found  in  the  "Dietary." 

Ice-cream  and  Water-ices. 

Ice-cream  and  water-ices  are  very  grateful  to  a  fever- 
ish child.  When  milk  and  cream  are  refused  they  will 
be  greedily  taken.  These  preparations  will  alleviate  the 
pain  on  swallowing  in  the  case  of  diphtheria.  They 
contain  considerable  nourishment,  but  must  be  given  in 
moderation.  ISTausea  and  vomiting  may  frequently  be 
controlled  by  them. 

68  Hutchison,  "Food  and  Dietetics/'  page  265. 


CHAPTEK  XXXIII. 

Milk  Idiosyncrasies  in  Children. 

Some  children  will  not  tolerate  milk;  physicians  fre- 
quently report  an  intolerance  of  milk  or  its  dilutions  in 
children.  This  condition  has  long  been  known  among 
adults.  We  frequently  hear  the  latter  say  that  milk  makes 
them  bilious,  that  it  is  not  tolerated,  and  that  they  feel 
uncomfortable  after  a  milk  diet.  While  this  condition 
is  of  much  rarer  occurrence  in  children,  certain  cases  are 
met  in  which  milk  is  not  tolerated.  It  has  been  the  milk 
itself  or  the  component  parts  of  the  same  that  has  dis- 
agreed in  certain  children  under  the  treatment  of  the 
writer.  Breast-milk  and  several  changes  of  wet-nurses 
gave  the  same  distressing  symptoms.  Cows'  milk  was 
not  tolerated,  and  was  discontinued  after  various  dilutions 
had  been  tried. 

The  following  case  will  serve  to  illustrate  what  is 
meant  by  the  above  condition: — 

Case  /.—An  infant,  M.  L.,  was  born  in  July,  1901.  The  weight 
at  birth  was  about  6  pounds.  The  mother  had  no  milk,  so  a  wet- 
nurse  was  secured.  The  infant  was  thus  nursed  for  the  next  three 
months.  The  child  gained  about  8  ounces  per  week  during  the 
month  of  July,  but  in  August  and  September  it  did  not  thrive. 

History  of  food  after  weaning:  When  the  child  was  weaned, 
in  October,  it  was  given  condensed  milk,  1  drachm,  to  12  drachms 
of  sterile  water,  to  which  1  drachm  of  lime-water  was  added.  The 
child  vomited  and  had  eructations,  although  it  had  from  one  to  two 
yellowish  stools  per  day.  When  this  child  was  weaned  it  was  al- 
ways constipated  and  required  an  enema  of  plain  water  to  relieve 
the  bowel.  The  stools  during  the  summer  months  contained  a 
great  deal  of  mucus,  which  was  shredded  and  yelloAvish  green  in 
color.  The  infant  was  colicky;  the  stools  had  a  very  sour  smell; 
the  child  frequently  had  an  explosive  vomit.  The  condensed  milk 
was  continued  through  the  month  of  October,  and,  as  the  child  did 
not  seem  to  thrive,  it  was  given  Just's  food.     This  the  child  re- 

(228) 


MILK  IDIOSYNCRASIES  IN  CHILDREN.  229 

fused,  so  Nestle's  food  was  substituted  and  seemed  to  agree.  When 
milk  was  added  the  child  vomited  a  sour-smelling  liquid,  and  later 
on  refused  the  Nestle's  food.  As  there  was  constant  anorexia, 
the  child  was  next  fed  with  Ridge's  food.  As  this  was  not  very 
well  borne,  a  trial  was  made  of  Allenbury's  food.  When  this  dis- 
agreed, the  child  was  placed  on  Eskay's  albumenized  food.  This 
also  was  not  tolerated,  and  the  child  was  given  some  strengthening 
meal.     This  was  not  borne  any  better. 

Examination:  On  November  24th  the  child  weighed  about  9 
pounds.  It  had  lost  8  ounces  the  week  previous  to  its  parents 
consulting  me.  This  loss  of  weight  disturbed  the  family  and  caused 
them  to  seek  a  change  of  diet.  The  examination  of  the  child 
showed  some  very  interesting  facts.  First,  the  general  appearance 
of  the  child  was  one  of  an  undersized,  undeveloped,  markedly  ra- 
chitic baby;  there  were  beaded  ribs;  the  ends  of  the  long  bones— 
particularly  the  radius,  ulna,  and  femur — were  markedly  rachitic. 
Subluxation  of  the  knee-joints  was  present.  The  head  of  the  child 
was  very  rachitic;  the  fontanelle  was  very  widely  open;  in  fact, 
the  fontanelle  was  three  times  the  size  of  that  of  a  normal  baby. 
The  extremities  were  extremely  cold;  the  circulation  was  very 
poor;  the  action  of  the  heart  was  very  feeble;  a  blowing  murmur 
was  distinctly  heard  at  the  apex  and  could  also  be  heard  in  the 
vessels  of  the  neck.  It  was  a  distinct  hsemic  murmur,  and  was 
attributed  to  the  profound  anaemic  condition  which  was  found  to 
exist. 

The  trained  nurse  in  charge  of  the  case  had  been  with  the  baby 
since  birth  and  had  stated  that  the  child  had  had  a  series  of 
spasms  which  were  not  only  regular,  clonic,  and  tonic  contractions, 
but  they  occurred  once  every  twenty-four  hours  at  a  certain  time 
of  the  day.  The  child  was  very  fretful,  very  nervous,  constantly 
irritable,  and  had  had  very  restless  spells  at  night,  which  disturbed 
its  sleep.  There  was  a  slight  eruption  around  the  anus;  the 
child  had  difficulty  in  taking  the  nipples  as  well  as  nursing  at  the 
breast. 

An  examination  of  the  throat  showed  congenital  adenoid  vege- 
tations. This  latter  condition  interfered  with  the  child's  proper 
feeding;  it  prevented  the  child  from  properly  taking  its  food  and 
breathing  at  the  same  time.  It  would  take  the  nipple  or  the 
breast  and  then  let  go,  in  order  to  breathe.  Spoon  feeding  was 
resorted  to  when  the  child  would  not  take  food  from  its  bottle. 
Attention  was  directed  to  the  rhino-pharynx.  By  gradual  cauter- 
ization the  child's  condition  was  so  markedly  improved  that  its 
general  condition,  with  the  appetite,  stools,  sleep,  and  weight,  all 
assumed  normal  tendencies. 


230  INFANT-FEEDING. 

Dietetic  treatment:    The  child  was  given  the  following: — 

IJ.  Whey    2       ounces. 

Milk    2%  ounces. 

Peptogenic  powder  ....  %  measure  of  the  metal  cap. 

Granulated  sugar y2  teaspoonful. 

Mix  the  above  and  peptonize  the  milk  by  a  slow  process  for 
about  ten  minutes,  and  when  cooled  to  the  proper  feeding  tempera- 
ture feed  the  above  quantity  every  three  hours. 

The  child  took  the  bottle  very  well;  in  fact,  took  4  ounces,  re- 
tained the  food,  and  seemed  to  like  it.  The  following  are  the 
nurse's  reports:  — 

"November  24th,  10.30  p.m.,  took  4  ounces;  has  not  vomited; 
seems  to  like  food." 

"November  25th,  4  a.m.,  took  4  %  ounces  of  food ;  retained, 
at  7  a.m.  took  nearly  4  ounces;  retained.  At  11  a.m.  child  crying 
and  abdomen  distended;  child  appears  colicky." 

A  warm  enema  consisting  of  2  pints  of  chamomile-tea  was 
ordered;  so  that  the  colon  and  rectum  were  thoroughly  flushed. 
The  child  was  instantly  relieved  after  some  cheesy  curds  and  mucus, 
plus  fseces,  were  washed  away.  These  fermentative  conditions — 
resulting  in  gaseous  eructations;  colicky,  distended,  tense  abdomen, 
with  crying  and  occasional  cheesy,  curdy  stools,  the  temperature 
frequently  reaching  101°  to  103°  F.  in  the  rectum,  occasional  vomit- 
ing, and  disturbed  appetite — were  invariably  noticed  when  milk, 
peptonized  or  predigested  or  in  any  form,  was  given  to  this  child. 

It  was  therefore  apparent  to  me  that  this  baby  would  not 
digest  milk,  and  hence  some  other  form  of  feeding  was  required. 
On  December  17th  a  new  form  of  feeding  was  commenced  which 
is  known  as  a  modified  form  of  malt-soup.  A  similar  plan  of  feed- 
ing is  used  extensively  abroad,  at  the  foundling  asylums  which  I 
visited;  notably  at  the  New  Berlin  Foundling  Asylum,  which  is 
under  the  supervision  of  Dr.  Finkeistein.  This  food  is  known  as 
Kellwr's  malt-soup.  Its  preparation  is  rather  difficult  unless  per- 
formed by  a  competent  chemist.  This  food  has  been  used  for  many 
years  in  the  nursling  pavilion  of  the  Kaiser  and  Kaiserin  Friedrich 
Children's  Hospital,  under  the  direction  of  Professor  Baginsky.  I 
am  indebted  to  the  New  York  Walker-Gordon  Laboratory  for  great 
care  in  the  preparation  of  this  food,  which  has  certainly  served 
me  very  well.  The  following  formula  was  used  in  the  beginning 
and  was  changed,  as  can  be  seen  by  studying  the  accompanying 
table: — 


MILK  IDIOSYNCRASIES  IN  CHILDREN. 


231 


Food  Ordered  at  Walker-Gordon  Laboratory. 
(Delivered  daily  as  ordered  for  Case  1.) 


Dec. 

20 

1901. 

Dec. 

24 

1901  . 

Jan. 

4 

1902  . 

Jan. 

9» 

1902  . 

Jan. 

12. 

1902  .   . 

Jan. 

21, 

1902  .    . 

Feb. 

7, 

1902  .   . 

Feb. 

18, 

1902  .   . 

Feb. 

22, 

1902  .   . 

Mar. 

1, 

1902  .   . 

Mar. 

3, 

1902  .   . 

Mar. 

6, 

1902  .    . 

Mar. 

10, 

1902  .   . 

Mar. 

17, 

1902  .   . 

April 
April 
April 
April 
April 
April 
May 

1, 
13, 
16, 

18, 

22, 
2(i, 
2, 

1902  .   . 
1902  .   . 
1902  .   . 
1902  .    . 
1902  .   . 
1902  .   . 
1902  .   . 

May- 

21, 

1902.   . 

May 

23, 

1902  .   . 

NO.   OF 

Oz. 

TUBES. 

4 

3 

4 

3 

8 

3 

8 

Wo 

8 

4 

5 

4 

8 

4 

4 

4 

4 

4 

8 

4 

4 

4% 

4 

5 

4 
4 

4 

% 

4)1 

41 

4 

4 

4 

5 

4 

5 

4 

5 

8 

6 

4 

6 

4 

6 

8 

6 

*6 

4 

8 
8 

8 

5 

8 

6 

8 

6 

4 

6 

§4 

6 

8 

6 

Dex. 

Wheat. 
Oz. 


1 

Same 
Same 
Same, 
Same. 
Same. 
Same, 
Same. 
Same 
2 


Milk. 
Oz. 


5% 


Water. 
Oz. 


Malt- 

EXT. 

Oz. 


1% 


lljS  Pot. 

Bicarb. 

Sol.    Drachms. 


(but  without  wheat). 

(but  with  dextrinized  wheat). 


i% 


2K 


(but  %  oz.  more  milk  to  each  tube). 
15" 

0 

3 

4 

3 

4 
20 
10 


2% 
3 
3 
3 

zy. 
iM 


2^ 


24 


24 


15K 
17)1 

'Si 


14)1 

14^| 

26 

13 

15 

22 


21 
21 
21 
21 


24 


3M 

3)1 
3)1 

41 
1% 


3^ 


2H 

2H 
2H 

2% 
2 


*Each  tube  of  4  ounces  of  distilled  water  and  3  drachms  of  Nestle's  food. 
fBarley-water.        JDistilled  water. 
§1%  ounce     s  of  Nestle's,  %  ounce  of  malt-extract,  and  24  ounces  of  distilled  water. 

(Case  II.) 


Date. 
1902. 

Dex. 

Wh. 

Dist. 

Barley 

Malt- 

11  56  Pot. 

No. 

Oz. 

Wheat. 

Milk. 

Water. 

Jelly. 

ext. 

Bicarb. 

Oz. 

Oz. 

Oz. 

Oz. 

Oz. 

Sol.    Drachms. 

May   28  .   . 

7 

6 

1¥ 

14 

28 

3 

% 

3)1 
3)1 

May    29  .   . 

7 

6 

lg 

24^ 

17% 

2 

May    30  .   . 

7 

7)1 

7)1 

i)! 

35 

14 

3% 

3)1 

2 

May    31  .   . 
June    2  .   . 

10 

7 

2V 
1)1 

52 
35 

21 
14 

3 

2 

June    5  .   . 

7 

7y2 

iy2 

35 

14 

4 

Keller's  Malt-soup. 

Take  of  wheat-flour  2  ounces  and  add  to  it  11  ounces  of  milk. 
Soak  the  flour  thoroughly  and  rub  it  through  a  sieve  or  strainer. 


232  INFANT-FEEDING. 

Put  into  a  second  dish  20  ounces  of  water,  to  which  add  3  ounces 
of  malt-extract;  dissolve  the  above  at  a  temperature  of  about 
120°  F.  and  then  add  2  1/2  drachms  of  11-per-cent.  potassium-bicar- 
bonate solution.  Finally,  mix  all  of  the  above  ingredients  and  boil. 
This  gives  a  food  containing:  albuminoids,  2  per  cent.;  fat,  1.2 
per  cent.;  carbohydrates,  12.1  per  cent.  There  are  in  this  mixture 
0.9  per  cent,  of  vegetable  proteids. 

The  wheat-flour  is  necessary,  as  otherwise  the  malt-soup  would 
have  a  diarrhceal  tendency.  The  alkali  is  added  to  neutralize  the 
large  amount  of  acid  generated  in  sick  children.  Biedert  emphasizes 
the  importance  of  giving  fat,  rather  than  reducing  its  quantity,  in 
poorly  nourished  children,  and  cites  the  assimilability  of  his  cream- 
mixture  or  of  breast-milk  in  underfed  children  as  proof  of  his  as- 
sertions. The  author  has  used  this  malt-soup  most  successfully  in 
the  treatment  of  athrepsia  (marasmus)  cases,  in  which  the  children 
were  simply  starved. 

On  studying  the  ingredients  one  can  easily  see  that  the  malt- 
extract  and  the  dextrinized  wheat  are  the  highly  nutritious  agents. 
We  know  that  dextrinized  wheat  is  very  well  absorbed  by  some 
of  the  youngest  infants.  The  addition  of  the  potassium  bicarbonate 
served  to  render  the  food  markedly  alkaline,  which  is  an  extremely 
important  thing.  When  milk  was  added  with  the  object  of  in- 
creasing the  percentage  of  fat  and  proteid,  we  deviated  from  the 
quantity  as  originally  recommended  by  Keller.  Colic  and  gastro- 
enteric fermentation  were  invariably  encountered.  A  study  of  the 
accompanying  weight-chart  is  extremely  interesting. 

Case  II. — The  child,  S.  N.,  born  of  healthy  parents,  was  put 
to  the  breast  on  the  second  day  after  birth.  On  the  third  day 
after  birth  there  was  a  profuse  flow  of  milk.  The  infant  appeared 
quite  well  satisfied  after  nursing. 

The  child  was  nursed  every  two  hours;  was  changed  from  the 
right  to  the  left  breast  at  every  other  feeding.  Fifteen  to  twenty 
minutes  after  each  nursing  there  were  symptoms  of  restlessness 
and  constant  crying.  The  legs  were  flexed  on  the  abdomen;  there 
were  eructations  and  all  the  evidences  of  colic.  The  child  cried  at 
least  one  hour,  until  it  fell  asleep  from  exhaustion.  This  state 
of  affairs  continued  each  day  for  at  least  two  weeks.  A  speci- 
men of  breast-milk  was  examined  by  a  chemist  and  was  found  to 
be  perfectly  normal  in  its  elements  and  in  their  relative  per- 
centages. 

The  family  was  greatly  distressed  at  its  continued  crying  and 
apparently  colicky  condition,  but  was  surprised,  in  spite  of  this 
condition,  to  find  that  the  infant  gained  between  4  and  6  ounces. 
It  was  necessary  to  give  1-  to  2-grain  doses  of  chloral  hydrate  at 


MILK  IDIOSYNCRASIES  IN  CHILDREN. 


233 


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234  INFANT-FEEDING. 

night  to  procure  sleep.  We  finally  decided  to  change  the  mother's 
milk  and  to  substitute  a  wet-nurse.  The  child  behaved  just  as 
badly  with  the  wet-nurse;  had  the  same  crying  spells  shortly  after 
nursing,  which  continued  frequently  for  one  hour.  When  the  breast 
was  discontinued  for  one  day  and  barley-water  or  albumin-water 
substituted,  the  child  would  appear  comfortable,  and  not  have  the 
pains  which  we  noted  while  feeding  breast-milk.  An  interesting 
point  is  the  fact  that  all  infants  having  the  milk  idiosyncrasy  had 
elevated  temperatures,  ranging  from  101°  to  102°  F.  continuously. 
The  stool  was  filled  with  large,  cheesy,  curdy  masses.  To  aid 
the  assimilation  of  the  milk,  small  doses  of  pancreatin  and  bi- 
carbonate of  soda  were  given;  with  the  idea  of  slightly  peptoniz- 
ing the  milk,  essence  of  caroid,  a/2  teaspoonful  before  each  feeding, 
was  also  prescribed.  In  addition  thereto  small  quantities  of  es- 
sence of  pepsin  and  hydrochloric  acid  were  given  after  each  feeding, 
to  aid  the  digestion  of  this  food.  Neither  of  these  medications 
relieved  the  condition,  and  I  finally  decided  that  breast-milk  was 
not  adapted  for  this  child.  We  next  resorted  to  very  diluted  cows' 
milk,  using  1  part  of  milk  with  3  parts  of  oatmeal-water.  We 
gradually  increased  the  strength  until  y2  milk  and  %  oatmeal- 
water  was  given.  Milk,  however,  in  any  form,  whether  diluted  or 
pure,  was  poorly  borne.  When  cereal  decoctions  were  substituted, 
they  were  invariably  better  tolerated.  The  same  was  true  when 
soups  and  broths  were  given.  The  latter  were  always  well  borne, 
and  the  moment  milk  was  added,  no  matter  in  what  form,  trouble 
was  immediately  encountered. 

Case  III. — Another  baby,  an  equally  instructive  case,  was 
brought  to  my  office  by  Dr.  Hecht,  of  West  Hoboken,  N.  J.  It 
could  not  assimilate  milk  in  any  form.  This  child  not  only  had 
dyspeptic  and  colicky  symptoms,  with  flatulence  and  cheesy  stools, 
but  also  evidences  of  fermentation  in  the  bowel,  and  invariably 
had  acute  febrile  attacks  with  temperature  ranging  from  101°  to 
103°  F.  whenever  milk  was  fed.  This  gastric  disturbance  was  only 
apparent  after  milk-feeding.  The  child  behaved  well  when  sub- 
stitute feeding  other  than  milk  was  given.  Almond-milk  was  one 
of  a  series  of  foods  given  which  was  not  only  well  borne,  but  was 
well  adapted  for  nourishing  when  milk  was  not  tolerated. 

It  was  found  wise,  if  4  ounces  of  milk  had  been  previously 
given,  to  substitute  at  the  next  feeding  4  ounces  of  barley-water  or 
oatmeal-water,  and  to  feed  4  ounces  at  regular  intervals  of  three  or 
four  hours  each. 

Almond-milk  can  be  given  in  the  same  quantity  and  at  the 
same  intervals  as  breast-milk.  It  must  be  sweetened  by  adding 
1  teaspoonful  of  sugar  to  each  4  ounces  of  food.     Delicate  infants 


MILK  IDIOSYNCRASIES  IN  CHILDREN.  235 

require  2  ounces — repeated  every  two  or  three  hours.  If  this 
quantity  is  well  borne  by  the  stomach,  then  1  ounce  more  can  be 
added  every  two  days.  Almond-milk  contains  vegetable  proteids 
and  is  exceedingly  valuable  as  a  milk-diluent.  It  serves  well  in- 
stead of  barley-,  rice-,  or  oatmeal-  water  if  it  is  sweetened  with 
cane-sugar. 


CHAPTER  XXXIV. 

Laboratory  Modification  of  Milk. 

It  is  now  several  years  since  a  Walker-Gordon  milk- 
laboratory  was  established  in  New  York.  Their  method 
of  feeding  infants  is  based  on  mixing  the  ingredients  in 
such  combination  that,  when  combined,  they  should  re- 
semble certain  chemical  formulae  of  breast-milk  at  various 
ages.  Blanks  are  given  the  physician,  which  are  filled  out 
according  to  the  individual  requirement.  The  age  and 
weight  are  noted.  Fat,  sugar,  proteid,  and  water  are  pre- 
scribed in  percentages.  We  are  therefore  able  to  state 
that  the  food  ordered  contains  a  definite  percentage  of 
fat,  sugar,  caseinogen,  and  lactalbumin.  The  same  is  also 
true  regarding  the  heating  of  food.  We  can  prescribe 
the  food  sterilized,  pasteurized,  or  raw.  A  great  many 
changes  can  be  made.  We  can  increase  or  decrease  the 
fat;    the  same  is  true  of  sugar  and  proteids. 

My  advice  to  those  using  modified  milk  is  to  begin 
with  low  proteids.  An  infant  at  birth,  if  deprived  of 
breast-milk,  should  never  receive  more  than  0.50  per  cent, 
of  proteids,  in  the  beginning  of  laboratory  feeding.  Some 
infants  do  very  well  on  0.25  per  cent,  of  proteids  soon 
after  birth.  It  is  a  simple  matter  to  note  the  infant's 
condition,  its  stools,  its  sleep,  and  its  weight. 

If  the  above-named  conditions  are  satisfactory,  then 
we  can  increase  the  proteids,  the  fat,  and  the  sugar.  Note 
conditions  every  day,  and  have  the  mother  or  nurse  in 
charge  of  the  infant  report  the  slightest  disturbance. 
Vomiting,  if  present,  its  frequency  and  character,  should 
be  carefully  noted.  So  also  should  colicky  symptoms, 
eructations,  flatulence,  and  greenish,  curded  stools. 

Constant  crying,  disturbed  sleep,  and  restlessness  are 
all  factors  that  need  correction  and  supervision. 
(236) 


LABORATORY  MILK.  237 

The  quantity  of  food  prescribed,  depends  upon  the 
requirements  of  each  child.  Some  children  can  take  3 
ounces  at  one  feeding  while  others  appear  satisfied  after 
taking  2  ounces  of  food. 

Examples. — For  a  child  at  birth. 

Fat   2.00  ^ 

Sugar   5.00 

Proteids 0.50 

Lime-water 5.00 


Formula  I. 


Or:— 


Fat   2.00 

Sugar   5.00 

Proteids 0.75 

Lime-water 5.00 


Formula  la. 


Milk,  raw,  pasteurized,  or  sterilized. 

Quantity  of  food  to  be  given,  2  ounces  every  two 
hours. 

My  preference  for  food  prescribed  at  a  laboratory 
where  germ-free  milk  is  obtainable  is  to  prescribe  it  raw. 
When  constipation  is  encountered  the  raw  milk  will  mod- 
ify such  conditions. 

If  diarrhoea  or  looseness  exist,  then  my  preference  is 
to  use  heated  milk :  sterilized  about  ten  to  twenty  minutes. 

If  the  infant  thrives,  the  ingredients  can  be  increased; 
also  the  quantity  at  each  feeding: — 

Fat   2.50  ^ 

^ Q™   I  Formula  II. 

Proteids 1.00    [ 

Lime-water 5.00  J 

Still  later,  if  conditions  warrant  it: — 

Fat   3.00  "} 

Sugar   6.00    (    ^  ,     TTr 

_     ,   . ,  >  Formula  III. 

Proteids 1.50    ( 

Lime-water 5.00  J 


238  INFANT-FEEDING. 

In  this  manner  we  can  gradually  increase  the  per- 
centage of  ingredients  until  whole  milk  is  ordered. 

When  abnormal  conditions  prevail, — such  as  loose 
bowels, — then  barley-water  can  be  substituted  for  the 
sterile  water. 

The  following  formula  was  recently  prescribed  at  the 
laboratory  for  a  child,  1  year  old,  with  very  loose  bow- 
els : — 


Whole  milk   15  ounces 

Rice-water    14  ounces 

Dextrinized  wheat   1  ounce 

Dry  cane-sugar 1%  ounces 

Cornstarch   2  teaspoonfuls  . 


Formula  IV. 


To  be  thoroughly  mixed,  sterilized  20  minutes,  and 
divided  into  five  feedings,  each  bottle  containing  6  ounces. 

When  the  bowels  acted  better,  and  had  a  more  solid 
consistency,  I  added  malt-extract,  1/2  teaspoonful  to  each 
bottle.  When  improvement  was  noted  the  above  formula 
was  changed  to:- — 

Whole  milk   28       ounces 

Barley-water    20       ounces 

Cornstarch   1       ounce  -  Formula  V. 

Dry  sugar 6       drachms 

Dextrinized  wheat   2y3  ounces 

Sterilize,  divide  into  eight  bottles  of  6  ounces  each. 

The  following  case  illustrates  successful  modified-milk 
feeding  with  milk  prepared  at  Walker-Gordon  labora- 
tory : — 

Baby  A,  4  months  old,  was  seen  by  me  September  19,  1901,  with 
the  following  history:  It  was  the  first  baby,  forceps  delivery, 
podalic  presentation;  weight  at  birth,  about  6  pounds.  Family  his- 
tory excellent.  Nursed  at  mother's  breast  about  four  weeks,  but, 
owing  to  a  scanty  flow  of  milk,  she  required  additional  hand-feeding. 
The  baby  received  milk  and  barley-water,  sterilized  or  boiled.  A 
bottle  was  given  after  each  nursing  (so-called  mixed  feeding). 

Result:  Constipation;  relief  given  by  soap-suds  enema.  This 
condition  lasted  about  six  weeks.  The  child  had  colic  of  a  very 
severe  form  and  also  tenesmus:    i.e.,  constant  straining. 


LABORATORY   MILK.  239 

Child  was  weaned  of  the  mother's  breast;  food  ordered  was: — 

Milk    8  ounces. 

Barley-water 16  ounces. 

Milk-sugar    3  teaspoonfuls. 

Lime-water   2  teaspoonfuls. 

Salt  10  grains   (pinch) . 

Sterilize  thirty  minutes,  divide  into  eight  feedings,  and  feed 
every  two  hours. 

When  about  2  months  old,  child  had  greenish,  spinach-like,  very 
slimy  stools,  also  containing  white  curds.  The  infant  appeared 
hungry  or  thirsty  all  the  time,  was  restless,  had  insomnia,  and  suf- 
fered with  colic.  There  was  no  vomiting.  A  physician  ordered 
the  milk  discontinued  and  barley-water  given  instead.  The  child 
became  extremely  emaciated;  hence  was  removed  to  the  sea-shore. 
At  the  sea-shore  Dr.  J.  ordered: — ■ 

Milk  1  ounce. 

Boiled  water   3  ounces. 

Milk-sugar  and  salt. 

This  food  was  quite  well  tolerated.  When  oatmeal-water  was 
given  instead  of  barley-water,  to  offset  the  constipating  effect,  a 
miliary  eruption  appeared. 

During  the  second  week  of  September  the  child  still  had  diar- 
rhoea. Stools  still  greenish,  containing  mucus  and  shreds.  The 
rectum  prolapsed  from  constant  tenesmus.  Cereal  milk  was  tried, 
but  with  no  success. 

The  above  is  the  clinical  history  given  to  me  by  the  mother  of 
the  infant. 

Present  condition:  A  very  frail-looking  infant,  rather  emaci- 
ated. Poor  circulation,  cold  extremities,  pallor  of  skin,  anus 
slightly  excoriated,  and  nsevus  on  right  side  of  thorax. 

Temperature  normal  in  rectum,  98  4/s°  F.;  pulse,  120;  respira- 
tion, 28.  Throat  normal,  tongue  moist  and  has  grayish-white,  fur- 
like coating.  Heart-sounds  feeble;  slight  bronchitis,  diffuse  sonor- 
ous and  sibilant  rales  heard  on  both  sides  of  the  chest.  Stomach 
very  markedly  distended.  Abdomen  tympanitic  on  percussion. 
Colon  distended.     Liver  enlarged.     Spleen  not  palpable. 

Diagnosis:  Chronic  dyspepsia,  atrophy  due  to  mal-assimilation 
of  food,  and  rickets. 

Prognosis:  Fair. 


240 


INFANT-FEEDING. 


Weight. 

September    19 8  lb.  15  oz.   (including  shirt  and  belly-band). 

25 9  lb.  12    " 


Gained 
October 

Gained 
October 

Gained 
October 

Gained 
October 

Gained 
October 

Gained    .... 
November    30 . 

With  clothes 


;.  13  " 

2 10  lb.     2  " 

6  " 

9 10  lb.     9  " 

7  " 

16 11  lb.     2  " 

9  " 

23 11  lb.  14  " 

12  " 

30 12  lb.     6  " 


15  lb.     7    " 


A  study  of  the  weight-chart  will  prove  very  interesting. 

The  dyspeptic  and  rachitic  baby  with  cold  extremities  is  to-day 
a  beautiful  child,  well  developed,  and  was  not  seen  by  the  author 
for  several  months — until  it  was  necessary  to  vaccinate. 

Ordered:  Syr.  rhei  arom.,  3j  every  four  hours,  to  cleanse  gastro- 
intestinal tract.    Also:  — 

B   Strychnine  sulphate 0.002 

Saccharin    0.06 

Decoction  of  cinchona   (llava) 60.0 

M.     Teaspoonful  after  feeding  three  times  per  day. 

The  above  as  a  cardiac  and  vascular  stimulant. 


Sept.  20th:    Food  ordered  at  Walker-Gordon  laboratory:  — 

Fat 2.50 

Sugar   6.00 

Proteids   1-50 

Lime-water  Vis 

Seven  feedings  of  6  ounces  each.  Use  raw  milk.  Feed  every 
two  and  one-half  hours. 

The  following  day  the  child  slept  from  8  p.m.  till  4  a.m. — eight 
hours  continuously.  Had  three  pasty  stools.  Infant  appeared  satis- 
fied after  bottle.    It  was  then  ordered  (September  22d)  :— 


LABORATORY  MILK.  2-il 

Fat    3.0 

Sugar   6.0 

Proteids  2.0 

No  alkalinity. 

Raw  milk.    Seven  feedings,  6  ounces  in  each. 
Feed  every  two  and  three-fourths  hours. 

Child  seemed  much  better  satisfied  after  feeding;  vomited  once; 
had  two  stools,  both  of  yellowish  color,  and  of  good  consistency. 
One  stool  at  5  a.m.  and  one  at  5  p.m. 

September  28th: — 

Fat   3.50 

Sugar   6.00 

Proteids 2.00 

Pasteurize  the  food.  Six  feedings  of  6  ounces  each.  Feed  every 
three  hours. 

When  bowels  acted  too  frequently  I  pasteurized  the  food;  not 
otherwise. 

October  6th  ordered:  Bran  and  sea-salt  baths  every  second 
night;  temperature  of  bath  95°  F. ;  followed  by  brisk  rubbing  to 
stimulate  the  circulation.  The  digestion  of  the  infant  being  excel- 
lent, stools  regular,  the  percentage  of  ingredients  was  increased: — 

Fat   4.00 

Sugar   6.00 

Proteids     2.50 

Use  barley -jelly  instead  of  water;  alkalinity,  5  per  cent.  Heat 
to  167°  F. 

Six  feedings  of  6  ounces  each. 

Feed  every  three  and  one-half  hours. 

Child  is  excellent,  gaining  in  weight;  sleeps  well;  stools  normal; 
has  no  colic.    Discontinued  laboratory  feeding. 

Home  modification: — 

Pure  raw   cows'   milk 30  ounces. 

Barley-water 18       " 

Peptogenic  powder 3  teaspoonfuls. 

Divide  into  six  bottles;  warm  each  bottle  before  feeding. 

Feed  every  three  and  one-half  hours. 

Add  the  barley-water  to  the  raw  milk  and  divide  into  six  equal 
bottles,  then  place  in  refrigerator  until  feeding-time.  At  feeding- 
time  empty  a  bottle  into  a  clean  saucepan,  add  the  peptogenic,  and 


242  INFANT-FEEDING. 

warm  to  the  temperature  of   100°   F.  for  ten  minutes;    then  boil 
quickly  for  one  minute  and  cool  to  feeding  temperature. 

For  the  relief  of  constipation: — 

Infus.   senna  comp 2  ounces. 

Saccharin    1  grain. 

M.     Teaspoonful  every  three  hours  until  bowels  move. 

Gradually  abstracted  one  ounce  of  barley-water  and  added  one 
ounce  of  pure  milk,  until  after  a  few  weeks  the  child  received  whole 
milk,  sweetened  with  one  teaspoonful  of  granulated  sugar;  8  ounces 
every  four  hours. 

Also  ordered  six  ounces  of  chicken-soup;  steak-juice,  gradually 
thickened  with  cereals;  some  egg-crackers,  zwieback,  and  bread- 
crumbs in  soup. 

Later: — 

Milk    (raw) 8  ounces. 

Cream     1/2  ounce. 

Granulated  sugar 1  teaspoonful. 

Warm  in  a  saucepan  and  feed  every  four  hours. 

Illustrative  Case — Unsuccessful  Laboratory  Feeding. — N.  R,  a 
healthy  female,  was  put,  soon  after  birth,  on  modified  milk. 

October  14th:  Fat,  2.0;  milk-sugar,  5.0;  albuminoids,  0.75; 
lime-water,  1/16.    Eight  feedings;    2  ounces  in  each. 

October  17th:  Constipation.  Fat,  2.5;  milk-sugar,  6.0;  albu- 
min, 1.0;  lime-water,  yi6.    Nine  feedings;  21/2  ounces  in  each. 

October  27th:  Fat,  3.0;  milk-sugar,  6.0;  albuminoids,  1.0;  lime- 
water,  Vis;  barley -jelly,  1/1B.    Ten  feedings;    3  ounces  in  each. 

November  5th:  Fat,  3.5;  milk-sugar,  6.0;  albuminoids,  1.0; 
lime-water,  Vis;    barley-jelly,  Vis-     Ten  feedings;    3  ounces  in  each. 

November  17th:  Fat,  4.0;  milk-sugar,  6.0;  albuminoids,  1.5; 
lime-water,  1/20;  no  barley.    Ten  feedings;  3  ounces  in  each. 

November  19th:  Curded  stools,  dyspeptic  diarrhoea.  Fat,  4.0; 
milk-sugar,  6.5;  albuminoids,  1.0;  lime-water,  Vac  Ten  feedings; 
3  ounces  in  each. 

The  child  did  not  increase  in  weight,  had  a  rectal  temperature 
of  100°,  slightly  furred  tongue,  vomited  curds,  had  greenish  stools 
containing  undigested  particles  of  fat  and  true  casein  and  large 
masses  of  mucus.  The  diagnosis  of  dyspepsia  infantum  was  made; 
hand-feeding  was  stopped,  the  child's  alimentary  tract  was  cleaned 
by  giving  cascara  sagrada,  and  a  proper  wet-nurse  was  secured. 
The  infant  at  this  time  was  about  6  weeks  old.  The  child  nursed 
very  well,  and  after  a  few  days  the  stools  were  normal,  both  in 


LABORATORY  MILK.  243 

consistency  and  color.  The  infant  gained  steadily  from  4  to  6  and 
sometimes  8  ounces  per  week,  until  she  was  7  months  old,  when 
suddenly  the  weight  remained  stationary.  The  child  was  bright 
and  cheerful,  but  I  deemed  it  necessary  to  have  the  milk  of  the  wet- 
nurse  examined  by  a  competent  chemist;  a  specimen  of  the  same 
was  secured  in  the  usual  manner  described  by  me  in  a  previous  sec- 
tion on  "Specimen  of  Breast-milk  for  Chemical  Examination." 
This  specimen  was  examined  for  the  author  by  John  S.  Adriance, 
the  chemist  of  the  Nursery  and  Child's  Hospital,  who  reported  the 
following:  — 

Fat    2.000  per  cent. 

Sugar 7.431  per  cent. 

Proteids 0.882  per  cent. 

Ash    0.162  per  cent. 

Total  soAds 10.475  per  cent. 

Water    S9.525  per  cent. 

Specific  gravity  at  70°  F 1.0316 

Reaction  alkaline. 

In  the  chemical  result  above  given  it  is  very  evident  that  a 
deficiency  in  the  proteids  exists;  hence  it  accounted,  not  only  for 
the  stationary  weight,  but  for  the  late  dentition.  The  child  did 
not  gain  an  ounce  in  one  month.  We  discharged  the  wet-nurse. 
The  following  food  was  ordered:  — 

Milk    3  ounces. 

Cream   2  teaspoonfuls. 

Oatmeal-jelly    3  ounces. 

Lime-water 1  drachm. 

Milk-sugar  1  teaspoonful. 

Salt    1  pinch. 

Sterilize  the  above  and  feed  every  three  hours,  the  above  quan- 
tity being  for  one  feeding. 

After  the  infant  had  taken  this  food  for  6  days  it  was  cheer- 
ful, had  had  one  and  two  yellow  stools  daily,  and  gained  6  ounces 
in  6  days. 

The  above  case  will  illustrate: — 

1.  That  the  child  was  decidedly  dyspeptic  while  taking  its 
modified  milk  for  about  6  weeks. 

2.  That  for  about  6  months  the  infant  thrived  very  well  on 
the  milk  of  a  wet-nurse. 

3.  That  the  stationary  weight  of  the  infant  and  the  chemical 
examination   of   the  milk   of  the   wet-nurse   showed   deficient   pro- 


244  INFANT-FEEDING. 

teids,  which  accounted  for  this  non-increase  in  weight  and  the  late- 
ness in  dentition. 

4.  That  a  proper  milk-mixture,  which  agreed  very  well,  suited 
the  requirement  of  this  infant,  and  emphasizes  the  fact  that  we 
must  individualize  in  each  and  every  case. 

According  to  Starr,  the  question  naturally  arises: 
"Why  should  a  food  capable  of  being  prescribed  to  ap- 
proach so  nearly  breast-milk  in  chemical  composition,  so 
uniform  in  its  make-up,  so  sterile,  and  so  easily  and  ac- 
curately varied  to  meet  digestive  emergencies,  fail  when 
put  to  a  clinical  test?" 

The  answer  is  that  it  is  impossible  to  make  an  emul- 
sion like  milk  from  its  component  parts  by  a  synthetic 
process.  Let  it  therefore  be  distinctly  understood  that, 
once  a  milk-emulsion  is  broken  up,  as  is  done  in  centri- 
fuging  milk  and  removing  the  cream,  mixing  the  whole 
will  never  restore  the  uniformity  of  the  emulsion  that 
existed  prior  to  this  division. 

Time  and  again  have  I  examined  a  drop  of  milk  under 
the  microscope  and  found  an  unevenly-divided  emulsion 
of  modified  milk,  resembling  colostrum-milk.  The  macro- 
scopical  examination  of  modified  milk  will  always  show 
a  large  amount  of  butter-fat  swimming  on  top  of  each 
bottle  of  milk  when  it  is  cool.  If  this  fat  is  part  of  the 
formula  prescribed,  then  the  modified  milk  does  not  con- 
tain its  original  amount  of  fat,  and  much  more  must  be 
prescribed,  to  allow  for  the  separation  of  the  same.  Hence 
it  would  seem  that  the  percentage  portion  of  the  food  must 
necessarily  be  incorrect. 

Starr  says,  also,  that  "in  its  composition  all  the  fat  is 
removed  by  a  separator,  and  the  food  as  prepared  for  the 
infant  is  a  recombination  of  this  fat  and  an  alkaline  so- 
lution of  the  proteids  and  sugar.  In  a  word,  the  natural 
emulsion  is  destroyed.  This,  I  think,  in  some  way  lessens 
the  digestibility  of  the  proteids  and  leads  to  conditions 
either  of  malnutrition  or  to  an  irritative  diarrhoea  with 
the  expulsion  of  the  undigested  proteids  in  the  form  of 


LABORATORY  MILK.  245 

compact  curds — and  this,  too,  despite  changes  in  the  pro- 
portion of  the  proteids;  for  the  partially  starved  children 
are  attacked  with  vomiting  or  diarrhoea  with  fever  if 
the  percentage  of  proteids  be  increased  (say,  to  2  per  cent, 
at  ten  months),  and  those  having  irritative  diarrhoea  are 
not  benefited  until  the  percentage  is  cut  down  to  a  starva- 
tion-point (0.75  per  cent,  in  a  child  of  three  months  still 
showed  numerous  curds  in  the  evacuations).  What  a  con- 
trast to  normal  breast-milk,  an  emulsion  having  over  2 
per  cent,  of  proteids  (Leeds)  ! 

"I  have  never  seen  an  infant  from  two  to  ten  months 
able  to  stand  a  laboratory-mixture  of  stronger  proteid 
percentage  than  1.50,  and  have  often  seen  cases  of  two 
months  and  more  unable  to  digest  a  percentage  of  0.50." 

This  last  statement  of  Starr's  I  cannot  indorse.  Sev- 
eral children  fed  by  me  were  able  to  digest  2  and  3  per 
cent,  of  proteids  at  6  to  10  months  of  age.  The  case  of 
successful  modified-milk  feeding  here  given  illustrates 
how  a  child  about  5  months  old  received  and  assimilated 
2  per  cent,  of  proteids,  and  when  less  than  6  months  old 
digested  2.50  per  cent,  of  proteids.  Thus  it  is  apparent 
that  weak,  dyspeptic  infants  require  individualization. 

In  domestic  modification,  of  course,  the  same  care 
must  be  taken  to  secure  clean,  pure  milk  and  cream  from 
healthy,  well-kept  cows.  This  is  quite  possible  now  in 
ISFew  York,  and  is  becoming  easier  each  year,  as  more 
attention  is  being  given  to  infant-feeding  and  greater 
demand  is  being  made  for  a  pure  milk-supply.  Pasteur- 
ization is  as  readily  done  in  the  nursery  as  in  the  labora- 
tory. Accurate  measurement  of  quantities  and  cleanliness 
of  vessels  and  feeding-bottles  is  equally  possible  and,  in 
my  experience,  quite  as  certain  at  home  as  in  the  -shop. 

"The  milk  and  cream  from  a  dairy  may  vary  slightly 
in  chemical  composition  from  day  to  day,  but  this  varia- 
tion seems  to  me  to  be  a  minor  detail,  and  of  questionable 
importance  when  compared  with  the  separator's  destruc- 
tion of  the  physical  properties  of  the  basal  milk.     One 


246  INFANT-FEEDING. 

certainly  would  not  sacrifice  everything  to  chemical  ac- 
curacy." 

Clinical  experience  has  demonstrated  the  fact  that 
some  children  will  thrive  on  condensed  milk  in  spite  of 
faulty  hygiene,  while  others  will  not  thrive  in  the  best 
environment  with  the  best  form  of  feeding;  again,  some 
children  will  thrive  on  modified  milk,  others  will  not. 
Some  cases  seen  by  the  author  suffered  with  intense  con- 
stipation, having  clay-colored  stools.  In  one  instance,  in 
which  two  children  in  one  family  were  constantly  fed  on 
modified  milk  of  varying  proportions,  the  formulae  were 
changed  at  least  a  half-dozen  times  with  the  usual  increase 
of  fat  and  sugar  and  lowering  of  the  proteids,  and  in  spite 
of  this  fact,  after  repeated  trials,  and  no  benefit,  this  feed- 
ing-method was  abandoned.  A  child  recently  seen  by  the 
author  did  not  gain  one  ounce  in  four  months.  This  was 
one  of  the  reasons  that  prompted  the  family  to  change 
both  the  physician  and  the  food.  The  child,  about  two 
years  old,  was  very  pale,  restless  at  night,  quite  peevish 
during  the  day,  and  decidedly  backward  in  development. 
It  could  neither  speak  nor  walk,  although  the  teeth  were 
well  developed.  From  the  time  the  modified  milk  was 
discontinued,  and  a  nitrogenous  diet  given,  the  infant  im- 
proved, and  from  last  reports  is  quite  well  developed. 

Do  not  let  us  blindfold  ourselves  with  the  belief  that 
an  infant  is  thriving  unless  our  baby  shows  a  regularity 
in  the  increase  of  weight,  sleeps  well  at  night,  for  at  least 
from  six  to  nine  hours  continuously,  and,  above  all,  as- 
similates its  food,  as  evidenced  by  regular,  unaided  move- 
ments of  the  bowels;  such  movements  should  be  once  or 
twice  in  twenty-four  hours,  have  a  yellowish-white  color, 
and  a  mustard-like  consistency.  If  the  stool  is  hard  or 
lumpy  or  pasty,  like  putty,  then  it  is  certainly  abnormal, 
and  shows  improper  food.  The  same  is  also  true  if  the 
stool  contains  white  particles  of  cheesy  curds,  showing  a 
casein  indigestion.  In  one  infant,  which  had  taken  modi- 
fied milk  continuously  for  seven  months,  an  obstinate  con- 


LABORATORY  MILK.  247 

stipation  was  only  relieved  after  full  doses  of  codliver-oil 
and  extract  of  malt  were  given  for  several  weeks — aided 
by  massage,  besides  changing  the  diet. 

It  is  therefore  very  necessary  continually  to  watch  the 
baby,  and  when  abnormal  conditions — such  as  anaemia — 
prevail  it  is  wise  to  give  restoratives  for  a  long  period  in 
addition  to  the  food.  Try  to  note  if  the  food  is  deficient 
in  its  nutritive  elements,  and,  if  so,  change  the  formula 
so  as  to  adapt  it  to  the  baby.  Do  not  give  medicine  when 
the  quality  or  quantity  of  food  is  deficient.  Remedy  the 
food  first;   then,  if  not  satisfied,  give  medication. 

PALLOR    OF    THE    SKIN. 

An  unusual  pallor  of  the  skin,  and  also  of  the  con- 
junctival mucous  membrane,  has  frequently  been  noticed 
in  modified-milk  babies.  In  one  instance  an  extreme 
leucocytosis  was  noticed  for  the  treatment  of  which  iron 
was  given.  An  examination  of  a  drop  of  blood  showed 
a  diminution  of  the  red  blood-corpuscles  and  an  excess  of 
the  white  blood-corpuscles.  A  decided  hsemic  murmur 
was  noticeable  in  the  vessels  of  the  neck,  in  a  child,  two 
years  old,  which  had  been  fed  continually  on  modified 
milk. 

Craniotabes,  softening  of  the  cranial  bones,  as  well 
as  very  late  closing  of  the  anterior  fontanelle  has  also 
been  observed  in  some  children  fed  with  this  form  of 
food.  A  boy,  4  years  old,  a  typical  Walker-Gordon  baby, 
who  was  fed  exclusively  on  modified  milk,  now  shows 
typical  knock-knees,  besides  having  been  under  the  treat- 
ment of  his  physician  for  a  general  furunculosis  of. the 
scalp.  The  furuncles  were  of  such  size  that  they  required 
incision  several  times;    others  opened  spontaneously. 

Thus,  I  fully  agree  with  Louis  Starr,  of  Philadelphia, 
who,  in  his  paper,69  says:  "I  must  not  be  understood  as 
condemning  laboratory-milk  absolutely ;  if  its  introduction 
has  done  nothing  else,  it  has  greatly  advanced  substitute 

69  Archives  of  Pediatrics,  page  7,  January,  1900. 


248  INFANT-FEEDING. 

infant-feeding,  by  fixing  the  attention  of  the  profession 
upon  the  importance  of  cleanliness  and  accuracy  in  the 
quantity  and  chemical  composition  of  cows'  milk  foods 
and  by  placing  the  whole  question  upon  a  higher  scientific 
plane  than  it  has  ever  reached  before." 

Sometimes  predigested  food  is  ordered  with  the  addi- 
tion of  peptogenic  powder,  the  predigestion  to  be  done  at 
the  laboratory.  A  great  many  physicians  who  formerly 
condemned  percentage  feeding  have  become  converted  to 
this  method. 

Constipation,  which  is  frequently  encountered,  can  be 
remedied  if  the  chemical  and  clinical  causes  are  consid- 
ered. Superheated  milk  is  one  of  the  main  causes.  In 
spite  of  the  many  failures  reported  by  feeding  sterilized 
milk,  we  see  hundreds  of  babies  brought  up  on  this  line 
of  feeding. 

Chemical  changes  are  produced  by  subjecting  the  milk 
to  a  temperature  of  212°  F.  for  thirty  minutes  and  fre- 
quently forty-five  minutes.  These  changes  take  place,  in 
the  most  vital  elements  of  milk,  such  as  albuminate  of 
iron,  phosphorus,  and  possibly  in  the  fluorin.  These  ele- 
ments are  present  in  a  vitalized  form,  as  they  are  derived 
from  tissues  that  contain  them.  When  we  consider  that 
children  require  phosphatic  and  ferric  proteids  in  a  living 
form,  then  we  cannot  continue  with  boiled-  or  sterilized- 
milk  feeding  for  a  too  prolonged  period  without  causing 
structural .  weakness. 

There  are  times  when  raw  milk  will  cause  too  fre- 
quent stools;  then  it  may  be  advantageous  to  resort  to 
pasteurization  or  to  heating  the  milk  to  167°  F.  for  about 
twenty  minutes. 

I  am  convinced  that  prolonged,  sterilized-milk  feeding 
will  result  in  rickets.  I  have  had  many  cases  of  weak 
spine  and  bony  structure  in  which  nothing  but  improper 
food  could  be  regarded  as  the  etiological  factor.  These 
children  were  among  the  well-to-do,  among  whom  excel- 
lent hygiene  and  proper  nursing  habits  were  rigidly  en- 


LABORATORY  MILK.  249 

forced.  Improvement  was  noted  when  sterilized  milk  was 
abandoned  and  raw-milk  food,  in  addition  to  raw  muscle- 
juice,  grape-juice,  and  orange-juice,  was  prescribed. 

A  great  many  unsatisfactory  reports  are  heard  regard- 
ing laboratory  feeding.  Some  condemn  laboratory  feed- 
ing because  it  is  patented.  Others  condemn  the  method 
after  noting  poor  results.  The  strongest  opponents  of  this 
method  are  Jacobi,  of  New  York,  and  Starr,  of  Philadel- 
phia. It  may  be  safe  to  add  that  they  may  yet  be  con- 
vinced of  the  value  of  procuring  sterile  food  handled  by 
competent  people  whose  scrupulously  clean  methods  must 
appeal  to  even  the  most  prejudiced. 

A  child  seen  by  me  recently,  in  consultation  with  Dr. 
John  Logan  and  Dr.  Julius  Martinson,  of  this  city,  may 
prove  very  interesting.  The  child  was  a  bottle-fed  infant 
— less  than  a  year  old — suffering  with  vomiting  and  diar- 
rhoea; the  symptoms  of  cholera  infantum  were  very  pro- 
nounced. The  diagnosis  of  acute  milk  poisoning  was 
made,  and  concurred  in  by  the  attending  physicians.  The 
milk  was  procured  from  a  small  laboratory  in  our  city. 
I  have  had  good  reason  to  complain  of  peculiar  methods 
of  handling  milk.  Sour  milk  has  been  sent  to  patients  of 
mine  by  unscrupulous  dairymen  after  they  had  secured 
evidences  of  my  good-will.  Surely  the  Walker-Gordon 
laboratory  cannot  be  held  responsible  for  the  mistakes  or 
carelessness  in  other  dairies  or  creameries. 

More  recently  the  author  has  tried  raw  milk  and 
cream  modified  at  the  laboratory,  and  has  noted  a  great 
difference  in  the  assimilation  of  such  modified  milk. 
Thus,  while  some  experience  herein  reported  has  been 
bad,  it  is  possible  that  a  good  part  of  the  fault  is  due  to 
overheating  the  milk.  Changing  the  character  Of  the  pro- 
teid  and  altering  the  chemical  relationship  of  the  various 
ingredients  must  change  its  assimilability,  and  hence  the 
author  would  urge  those  who  use  the  laboratory  to  insist 
upon  having  formulae  compounded  by  using  raw  milk 
and  fresh  cream. 


CHAPTER  XXXV. 

Fokced  Feeding. 

This  is  commonly  known  as  gavage.  This  consists  in 
forcing  a  small  feeding-tube,  a  No.  Y  rubber  catheter, 
through  the  mouth  and  pushing  it  forcibly  toward  the 
pharynx  and  directly  into  the  stomach.  This  feeding- 
tube  consists  of  a  black  hard-rubber  or  glass  funnel  to 
which  is  attached  a  piece  of  rubber  tubing  about  ten 
inches  long;  then  a  small  glass  tube  (a  connecting  tube) 
over  which  is  drawn  the  rubber  No.  Y  catheter.  In  case 
of  emergency,  nothing  is  handier  as  a  connector  than 
the  glass  portion  of  the  ordinary  medicine-dropper,  the 
smaller  end  will  serve  to  connect  with  the  rubber  catheter 
mentioned  above,  and  over  the  larger  portion  of  the  medi- 
cine-dropper we  draw  the  rubber  tubing  connected  with 
the  funnel.  This  little  apparatus  has  been  very  neatly 
combined  for  the  author's  use  by  Messrs.  George  Tiemann 
&  Co.     (See  Fig.  40.) 

Having  pushed  this  small  catheter  into  the  stomach, 
we  pour  the  food,  usually  several  ounces  of  peptonized 
milk,  or  dextrinized  barley  and  milk,  or  albumin-water, 
or  the  white  of  a  raw  egg  mixed  with  half  of  a  teacup  of 
coffee  and  milk;  or,  if  desired,  a  good  concentrated  soup, 
or  bouillon,  or  broth,  can  be  used.  The  same  interval 
governing  ordinary  meals  should  be  more  strictly  adhered 
to  while  this  process  of  feeding  is  used.  It  is  well  under- 
stood that  all  instruments,  utensils,  and  food  must  be 
strictly  clean  and  sterile. 

Place  the  child  flat  on  its  back,  and,  first,  pin  either 

a  heavy  blanket  or  a  stout  sheet  securely  behind  the  body 

so  that  the  hands  are  pinned  down;    have  the  assistant 

hold  the  child's  elbows  securely  on  each  side;   then  force 

(250) 


FORCED  FEEDING. 


251 


the  mouth  open  and  quickly  pass  the  catheter,  pour  the 
food  into  the  funnel,  and  when  the  funnel  is  empty  with- 
draw the  catheter  as  quickly  as  possible.  If  this  forced 
feeding  is  done  very  slowly  or  clumsily,  then  nausea  and 
sometimes  vomiting  will  be  produced  thereby.  Hence, 
the  technique  should  be  carried  out  as  carefully  as  pos- 
sible. 


Fig.  40. — Author's  Apparatus  for  Irrigating  Rectum  and  well 
Adapted  for  Stomach-washing  (Lavage)  and  also  for 
Forced  Feeding  (So-Called  Gavage).  Also  Useful  in  Nasal 
Feeding. 

Great  care  should  be  used  in  gavage.  When  children 
have  teeth,  the  nurse  must  separate  the  jaws.  For  this 
purpose  a  piece  of  cork  or  a  spoon  covered  with  linen  will 
answer  as  a  mouth-gag.  Accidents  may  happen  if  this 
precaution  is  not  taken.  The  writer  has  seen  several  chil- 
dren who  had  bitten  the  catheters  and  swallowed  them. 
In  one  of  these  cases  the  tube  was  easily  dislodged  by  an 
emetic.     Another  required  a  gastrostomy. 


252  INFANT-FEEDING. 


NASAL    FEEDING. 


]STasal  feeding  has  long  been  in  use  where  diseases  of 
the  mouth  or  spasm  of  the  jaw  or  intubation  in  diphtheria 
rendered  swallowing  difficult.  A  thin  rubber  catheter 
is  attached  to  a  long  rubber  tube  ending  in  a  funnel; 
this  is  the  same  apparatus  that  has  been  described  on  page 
250. 

Modus  Operandi. — Lay  the  child  flat  on  its  back  and 
have  a  large  sheet  pinned  over  the  body,  so  that  the  hands 
are  firmly  held;  have  the  feeding-mixture  all  prepared, 
so  that  no  time  will  be  lost.  A  soft-rubber  catheter,  lubri- 
cated with  vaselin  or  glycerin,  is  gently  pushed  into  the 
nostril  and  glided  through  the  pharynx  into  the  oesopha- 
gus and  stomach.  When  the  tube  is  in  the  stomach,  pour 
the  required  •  amount  of  food  into  the  funnel  so  that  it 
flows  in  the  stomach.  When  the  proper  amount  has  been 
used,  withdraw  the  catheter  from  the  nose,  and  boil  it. in 
warm  water  to  properly  sterilize  it  for  the  next  feeding. 

Quantity  of  Food.  —  The  quantity  of  food  used  in 
nasal  feeding  should  be  somewhat  less  than  is  ordinarily 
used  in  health.  It  is  understood  that  only  liquid  foods 
— like  peptonized  milk,  sterilized  milk,  soups,  and  broths, 
or  bouillon — can  be  used  for  feeding  in  this  manner.  A 
thin  emulsion  of  egg  can  also  be  used.  Owing  to  the  fre- 
quency of  both  nausea  and  vomiting,  which  may  be  in- 
duced by  irritation  of  the  fauces,  while  the  tube  is  gliding 
through  the  pharynx  into  the  oesophagus,  a  much  larger 
interval  must  be  given  between  the  feedings.  It  is  de- 
sirable to  introduce  the  tube  rapidly  and  remove  it  rapidly 
if  it  is  at  all  possible.  Accidents  will  result  in  nasal 
feeding  if  a  large  quantity  of  liquid  food  is  regurgitated 
through  the  oesophagus  into  the  mouth  and  aspirated 
through  the  larynx  into  the  trachea. 

In  some  instances  it  is  easier  to  pass  a  soft,  flexible 
catheter  through  the  right  or  left  nostril  into  the  oesopha- 
gus, and  forcibly  push  the  same  into  the  stomach.  This 
is  a  very  simple  process,  and  I  have  never  yet  been  able 


FORCED  FEEDING.  253 

to  pass  the  tube  into  the  larynx  while  gliding  it  toward 
the  oesophagus.  All  food  should  be  given  warm — prefer- 
ably between  98°  and  100°  F.  Small  quantities  of  milk, 
strained  gruel,  broth,  or  albumin-water  will  be  far  better 
digested  than  heavier  food.  In  some  instances,  where 
milk  is  not  well  borne,  the  ordinary  unsweetened  cream, 
in  the  proportion  of  1  teaspoonful  of  cream  to  3  ounces 
of  water,  will  serve  quite  well.  In  other  cases  I  have 
used  very  successfully  several  teaspoonfuls  of  Mellin's 
food  diluted  with  an  ounce  of  raw  milk,  to  which  1 
ounce  of  boiling  water  was  added.  This  latter  mixture 
is  highly  nutritious,  and  scalds  the  milk,  and  does  not 
require  either  pasteurization  or  sterilization.  Eskay's  food 
has  served  me  very  well  in  one  case  of  gavage.  Meat-juice 
and  expressed  steak-juice  or  roast-beef  juice  should  not 
be  forgotten. 


CHAPTER  XXXVI. 

Feeding  in  Diphtheria-Intubation  Cases. 

When  an  infant  has  a  foreign  body — the  intubation- 
tube — in  its  throat,  swallowing  is  more  difficult,  because 
the  epiglottis  cannot  close  entirely.  Frequently,  while 
swallowing  there  is  coughing,  gagging,  and  regurgitation, 
caused  by  fluids  (food)  trickling  into  the  trachea.  In 
this  manner,  it  is  claimed,  schluck-pneumonia  has  fre- 
quently been  caused,  though  Northrop  and  many  others 
deny  the  possibility  of  this  condition.  If  the  child's  head 
is  turned  to  one  side — either  side — and  swallowing  is  pro- 
voked in  this  manner,  we  can  sometimes  avoid  this  trick- 
ling into  the  trachea.  Another  method  is  to  lay  the  child 
flat  on  its  back  and  allow  the  head  to  hang  lower  than  its 
body,  and  to  feed  slowly  with  a  spoon.  This  is  known  as 
the  Casselberry  method  of  diphtheria  feeding. 

If  this  method  is  not  satisfactory,  and  if  we  find  that 
"we  cannot  get  enough  food  into  our  patient,  then  we  can 
resort  to  rectal  feeding. 

Clinical  Illustration  of  Rectal  Feeding  in  Diphtheria. — The  fol- 
lowing clinical  record  will  illustrate  the  manner  employed  in  rectal 
feeding  in  private  practice,  with  the  aid  of  a  competent  trained 
nurse,  in  a  case  of  severe  laryngeal  diphtheria  which  required  in- 
tubation;   child  seen  in  consultation  with  Dr.  H.  Weinstein:- — 

Feeding  by  mouth  was  discontinued  while  the  child  had  a  tube 
in  its  larynx:  in  all,  a  period  of  five  days. 

The  feeding  was  accomplished  by  first  flushing  the  rectum 
and  colon  with  a  soap-suds  enema  to  clean  the  bowel.  After  the 
bowel  was  emptied  the  peptonized  food  was  introduced  high  into 
the  colon.    Food  used: — 

Peptonized  milk   1  ounce. 

Starch-water 1  ounce. 

To  make  starch-water  take  1  teaspoonful  of  starch  to  1  ounce 
of  water. 

(254) 


FEEDING   IN   DIPHTHERIA-INTUBATION    CASES.  255 

Alternate  with:  — 

Peptonized  yolk  of  egg. 
Starch-water,  1  ounce. 

Feed  per  rectum  every  four  hours. 

One  day's  record  of  case: — 

9.00  a.m.     Intubated. 
10.30     "        Rectal  irrigation  (soap-suds). 
11.00     "       Nutritive  enema   (which  was  retained)  : — 
Peptonized  yolk  of  egg. 
Starch-water,  1  ounce. 
2.00  p.m.     Bowel  irrigated. 
3.00     "       Nutrient  enema  (which  was  retained) :  — 

Peptonized  milk 1  ounce. 

Starch-water 1  ounce. 

6.00    "        Greenish  stool  with  undigested  milk-curds. 

Bowel  irrigated. 
7.00     "        Nutrient  enema   (which  was  not  retained)  : — 
Peptonized  yolk  of  egg. 
Starch-water,  1  ounce. 
10.00     "       Bowel  irrigated. 
10.30     "       Nutrient  enema    (which  was  retained)  :  — 

Peptonized  milk   1  ounce. 

Starch-water 1  ounce. 

Bear  in  mind  that  the  rectum  absorbs,  and  does  not 
digest.  Hence,  all  food  must  be  peptonized.  The  method 
is  very  simple.  First:  Always  cleanse  the  rectum.  This 
is  done  by  washing  the  rectum  with  an  enema  of  a  pint 
of  soap-water  made  by  dissolving  ordinary  Castile  soap 
or  glycerin  soap  in  warm  water.  The  temperature  of  the 
soap-water  should  be  100°  to  110°  F.  Quantity,  from 
1  to  2  pints.  After  the  rectum  is  cleaned,  and  the  faecal 
movements  all  passed,  it  is  advisable  to  wait  about  five 
minutes  to  give  the  rectum  a  chance  to  rest.  Then  we 
proceed  to  inject  the  rectum  with  a  suitable  quantity  of 
peptonized  egg.  Small  quantities  are  better  borne  than 
large  quantities;  hence,  no  more  than  1  to  2  ounces  should 
be  thrown  in  at  one  time. 


256  INFANT-FEEDING. 

For  rectal  feeding  the  following  are  required: — 

1.  Fairchild  peptonizing  tubes. 

2.  Starch-water  made  by  adding  1  teaspoonful  of 
starch  (raw)  to  1  ounce  of  water  (lukewarm). 

3.  Fresh-laid  eggs. 

4.  Fresh  raw  milk. 

5.  Rectal  syringe  or  a  fountain-syringe. 

6.  Colon-tube  for  flushing  the  colon  and  rectum;  the 
same  tube  can  be  used  for  injecting  the  peptonized  food 
after  the  enema  has  acted. 

The  following  formula  will  give  an  idea  of  the  way 
in  which  food  is  to  be  prepared  for  rectal  injection: — 

Take  2  teaspoonfuls  of  ordinary  starch  and  rub  the 
same  up  with  an  ounce  of  lukewarm  water.  This  makes 
a  very  milky  mixture.  To  this  mixture  we  add  the  yolk 
of  1  egg,  and  one-half  of  an  ordinary  Fairchild  pepto- 
nizing tube.  This  is  to  be  slowly,  but  forcibly,  injected 
into  the  rectum.  Various  methods  of  injecting  can  be 
used,  the  simplest  being  with  the  aid  of  a  bulb  rectal 
syringe,  known  as  the  infant's  rectal  syringe.  (See  Fig. 
42.) 

Another  method  consists  in  pouring  this  emulsion  of 
starch-water  and  peptonized  egg  into  a  funnel  ending  in 
a  rectal  tube,  a  so-called  rectal  feecling-tube  made  by  Tie- 
mann,  of  ]STew  York  City.     (See  Fig.  40.) 

The  secret  of  success  is  undoubtedly  the  amount  of 
food  brought  into  a  child's  body  during  its  illness,  and, 
the  more  food  absorbed  the  greater  resistance  will  the 
child  have.  It  is  advisable  not  to  overtax  the  rectum; 
hence,  my  method  of  feeding  is  to  use  the  peptonized 
yolk  of  egg  with  starch-water  as  mentioned  above,  and 
follow  it — four  hours  later — by  substituting  an  ounce  of 
peptonized  milk  instead  of  the  yolk  of  egg. 

With  this  ounce  of  milk  an  ounce  of  starch-water 
should  be  combined.     If  there  is  looseness  of  the  bowels, 


FEEDING   IN"   DIPHTHERIA-INTUBATION    CASES.  257 

and  the  food  will  not  remain  in  the  rectum,  then  1  or  2 
drops  of  the  ordinary  tincture  of  opium  added  to  each 
enema  will  soon  quiet  the  irritation  of  the  rectum,  and 
thus  aid  in  retaining  the  nutrient  enema. 

At  the  Willard  Parker  Hospital  feeding  in  diphtheria 
is  chiefly  done  by  gavage  through  the  nose.  The  child 
is  placed  on  its  back  and  fed  in  the  same  manner  as  de- 
scribed by  me  under  the  heading  "Mouth  Gavage."  While 
making  rounds  through  the  wards  I  have  seen  children 
gavaged  through  the  nose,  some  lying  on  their  backs 
and  others  while  sitting  erect.  The  only  objection  to  this 
form  of  feeding  is  the  possibility  of  pushing  membrane 
downward  through  the  nose  or  naso-pkarynx.  This  might 
result  in  an  infection  of  a  healthy  surface  or  in  denuding 
membrane;  epistaxis  is  likely  to  occur. 


CHAPTER  XXXVII. 

General  Rules  for  Rectal  Feeding. 

In  another  chapter  entitled  "Rectal  Feeding  in  Diph- 
theria" attention  has  already  been  given  to  the  method 


Fig.  41. — Author's  Double-Current  Rectal  Tube  for  Flushing 
the  Colon  and  Rectum  and  Used  for  Rectal  Feeding. 


Fig.  42. — Rectal  Syringe. 

of  cleansing  the  rectum,  and  also  to  the  injection  of  foods. 
The  same  rules  are  applicable  when  there  is  excessive 
(258) 


GENERAL    RULES    FOR    RECTAL   FEEDING.  259 

irritability  of  the  stomach,  with  constant  vomiting  and 
where  it  is  desirable  to  give  the  stomach  absolute  rest. 


Fig.  43. — Rectal  Syringe. 


Small  quantities  properly  injected  will  be  retained  and 
absorbed  much  easier  than  large  quantities  of  food,  which 
will  merely  serve  as  irritants  and  be  expelled. 


CHAPTER  XXXVIII. 

Feeding  Children  Afflicted  with  Cleft  Palate. 

An  infant  born  with  cleft  palate  has  a  greater  struggle 
for  existence  than  a  child  born  healthy,  without  this  de- 
formity. It  is  advisable  to  give  the  best  possible  food, 
and,  therefore,  breast-milk  only  should  be  used.  The  milk 
should  be  drawn  from  a  woman's  breast  as  previously  de- 
scribed in  the  section  on  "Specimen  of  Breast-milk  for 
Chemical  Examination." 

An  artificial  nipple  should  be  attached  to  the  feeding- 
bottle,  and  to  the  former  should  be  attached  a  flap  of 
India  rubber  so  made  that  it  fits  the  roof  of  the  mouth. 
The  pressure  of  the  nipple  against  the  piece  of  rubber, 
when  in  position,  converts  it  into  an  artificial  palate-piece, 
and  prevents  the  escape  of  the  milk  into  the  nose  during 
the  effort  of  swallowing.  This  shield  is  chosen  to  avoid 
permitting  curdled  milk  to  pass  into  the  recesses  of  the 
turbinated  bones  and  to  cause  aphthous  patches. 

It  is  advisable  to  operate  on  an  infant  for  this  de- 
formity between  the  third  and  sixth  months  of  its  life, 
if  sufficient  progress  in  its  development  will  warrant  it. 


(260) 


CHAPTER  XXXIX. 


Infant-stools. 


Stool  of  a  Nursling. — The  stool  of  a  nursling  or  a 
baby  on  an  exclusive  milk  diet  should  be  yellowish  in 
color,  smeary  or  pasty-like  in  consistency,  and  have  an 
acid  reaction.  The  smell  should  be  faintly  acid,  but  not 
disagreeable.  The  color  is  due  to  bilirubin,  and  the  reac- 
tion depends  on  the  presence  of  lactic  acid,  the  source 
of  which  is  the  milk-sugar.  The  only  gases  present  are 
H  and  C02.  According  to  Escherich,  H2S  and  CH4,  to 
which  the  odor  of  adult  stools  is  due,  are  not  present. 
There  are  no  peculiar  albuminoids.  Those  existing  in 
mothers'  milk  seem  to  be  entirely  absorbed.  Peptone  ex- 
ists in  trifling  amount.  Srigar  is  not  present.  Pancreatic 
ferment  is  absent,  and  sometimes  traces  of  pepsin  have 
been  found.  Mucus  is  always  present  in  considerable 
quantity;    also  columnar  intestinal  epithelium. 

In  the  stools  of  nurslings  large  quantities  of  lactate 
of  lime  can  be  found;  so  also  we  frequently  find  oxalate 
of  lime,  depending  on  the  quantity  of  oxalate  of  lime  in- 
gested. UfTelmann  has  noted  the  presence  of  bilirubin 
crystals  in  the  stools  of  nurslings,  in  perfectly  healthy 
children. 

Miller,  who  carefully  studied  the  various  micro- 
organisms in  the  mouth,  found  that  most  of  them  could 
again  be  found  in  the  intestinal  canal.  He  further  found 
that  certain  germs  possessed  diastasic  properties  and  were 
capable  of  producing  lactic-acid  fermentation.  In  the 
milk-feces  of  nurslings  Escherich  found  two  germs;  the 
one  he  called  bacterium  lactis  aerogenes  (or  bacterium 
aceticum,  Baginsky)  and  the  other  the  bacterium  coli 
commune.     In  the  meconium  he  found  proteus  vulgaris, 

(261) 


2G2  INFANT-FEEDING. 

streptococcus  coli  gracilis,  and  bacillus  subtilis.  The 
number  of  stools  during  the  first  two  weeks  is  from  3  to 
6  daily.  After  the  first  month  the  average  is  2  stools 
daily;  many  infants  have  1,  others  3  stools  daily.  This 
latter  is  due  largely  to  the  excessive  quantities  of  water 
given  to  infants. 

As  soon  as  the  exclusive  milk  diet  is  changed  to  the 
mixed  diet  we  then  lose  the  characteristic  infantile  stool, 
and  it  resembles  more  that  of  an  adult,  though  remain- 
ing softer  and  thinner  throughout  infancy.  The  stools 
become  darker  in  color,  assume  the  adult  odor,  and  have 


Fig.  44. — Schering's  Formalin  Disinfecting-lamp.    Well  Adapted 
as  a  Deodorizer  in  the  Nursery. 

more  varieties  of  bacteria  than  those  previously  mentioned 
as  found  in  the  stool  of  a  milk  diet. 

Reaction  of  Stools. — Reaction  of  stools  in  diarrhoeal 
disease  and  in  health  is  chiefly  acid  or,  next  in  frequency, 
neutral.  Alkaline  stools  are  rare.  Green-grass  stools, 
usually  acid,  are  seen  in  the  early  stage  of  dyspeptic  diar- 
rhoea, the  color  from  a  pale  greenish  yellow  to  grass-green, 
owing  to  improper  food. 

Wegscheider  has  shown  that  the  green  color  is  the 
result  of  preformed  biliverdin.  The  condition  in  the  in- 
testine, upon  which  the  transformation  of  bilirubin  into 
biliverdin  depends,  has  been  generally  regarded  as  one  of 
acid  fermentation. 


INFANT-STOOLS.  263 

Experiments. — Pfeiffer's  experiments70  show  this  for- 
mer opinion  to  be  wrong.  He  found  that  none  of  the 
acids  formed  in  such  fermentation — lactic,  acetic,  butyric, 
propionic,  etc. — added  to  yellow  stools  outside  the  body, 
turned  them  green,  but  that  they  made  them  deeper  yel- 
low. But  dilute  alkaline  solutions  added  to  fresh  yellow 
stools  turned  them  green  after  an  exposure  of  thirty  to 
sixty  minutes,  and  strong  solutions  turned  them,  first, 
brown;    later,  after  exposure  to  air,  intense  green. 

Typical  Green  Stools. — Typical  green  stools  can  be 
produced  by  giving  an  infant  2  or  3  grains  of  bicarbonate 
of  soda.  This  I  have  tried  dozens  of  times;  the  soda  must 
be  given  for  a  few  days.  This  explains  Pfeiffer's  alkaline 
theory.  Typical  green  stools  can  also  be  produced  by 
giving  small  or  even  large  doses  of  calomel.  If,  after 
having  given  bicarbonate  of  soda  and  produced  green 
stools,  we  give  diluted  hydrochloric  acid  in  5-  to  10- 
drop  doses,  the  yellow  color  will  reappear  in  a  few  days. 
Rhubarb  will  also  produce  a  yellow  stool. 

Stools.  —  Stools  which  are  pale  yellow  when  dis- 
charged, and  which  afterward  become  green,  are  often 
seen  in  disease.  They  may  be  themselves  neutral  or  alka- 
line in  reaction;  this  latter  may,  however,  depend  on  the 
admixture  of  urine.  An  excess  of  bile  may  often  cause 
very  green  stools. 

Brown  Stools. — Brown  stools  may  be  due  to  changed 
biliary  pigment  and  to  drugs:  e.g.,  bismuth  causes  the 
well-known  dark  stool.  So  also  tannic  acid  and  all  iron 
salts  give  the  dark  stool,  which  varies  from  a  deep  brown 
to  a  black  color. 

Blood  in  Stools. — Blood  from  the  stomach  or  small 
intestine  frequently  gives  the  stool  a  black  color  resem- 
bling tar.  Thus,  a  practical  point  in  Boas's  "Diagnostik 
der  Magen-  und  Darmkrankheiten"  is  that,  the  brighter 


70  "Verdauung  im  Sauglings-alter  bei  Krankhaften  Zustanden," 
'Jahrbuch  fur  Kinderheilkunde,"  B.  28,  page  164. 


2G4  INFANT-FEEDING. 

the  color  of  the  blood,  the  lower  down  near  the  rectum 
and  anus  must  the  pathological  lesion  be  looked  for;  the 
darker  the  blood,  the  higher  up  must  the  cause  be  found: 
e.g.,  the  diseased  conditions  exist  in  the  stomach,  duode- 
num, jejunum,  etc.,  if  the  stool  contain  black  blood. 
If  the  corpuscular  elements  of  the  blood  are  wanting, 
then  the  presence  of  blood  can  only  be  positively  diag- 
nosticated by  either  a  microchemical  examination  or 
by  means  of  the  spectroscope.  The  presence  of  red  blood- 
corpuscles  must  always  be  regarded  as  a  pathological 
factor. 

Brown  Stools;  Muddy  Stools. — A  brown  stool  in  an 
infant  is  frequently  caused  by  a  diet  of  animal  food  or  by 
a  diet  principally  of  broth.  These  stools  have  no  distinct 
consistency  nor  reaction.  In  dyspeptic  diarrhoea  or  in 
some  forms  of  enterocolitis  we  have  very  offensive  stools, 
and  they  resemble  muddy  water;  with  the  latter  there  is 
considerable  flatus  during  each  movement. 

White  or  Light-Gray  Stools.  —  White  or  light-gray 
stools  usually  are  of  a  putty-like  consistency,  sometimes 
like  dry  balls  on  a  diaper;  sometimes  they  appear  like 
ashes.  Usually  they  are  very  offensive,  consisting  prin- 
cipally of  fat.  There  is  scarcely  a  trace  of  bile,  or  the 
latter  may  be  absent  altogether. 

Mucus.—  Mucus  is  always  present  in  all  healthy  stools, 
and  is  so  well  mixed  with  the  stool  that  it  does  not  appear 
as  mucus  to  the  naked  eye.  Any  appearance,  therefore, 
of  mucus  easily  visible  should  be  regarded  as  abnormal. 
Mucus  is  present  in  every  form  of  intestinal  disease :  very 
abundant  in  inflammatory  conditions  affecting  the  large 
intestine,  more  so  than  in  those  affections  of  the  small 
intestine,  and  especially  so  in  inflammatory  conditions  of 
the  colon,  both  acute  and  chronic. 

Jelly-like  Masses.  —  Jelly-like  masses  of  shreds  of 
mucus,  and  cases  where  the  stool  consists  chiefly  of  mucus, 
show  that  the  affection  is  confined  to  the  lower  portion  of 
the  colon  or  that  it  is  located  in  the  rectum. 


INFANT-STOOLS.  2G5 

Long  Shreds  of  Mucus. — Long  shreds  of  mucus,  fre- 
quently resembling  false  membrane,  are  often  found  in 
catarrh  of  the  large  intestine.  If  the  shreds  of  mucus 
are  intimately  mixed  with  the  stool,  then  we  must  look 
for  the  lesion  quite  high  up,  and  if  it  comes  from  the 
small  intestine  it  is  usually  stained  from  bile.  If  the 
lesion  is  low  down  the  mucus  is  not  intimately  mingled 
with  the  stool. 

Dyspeptic  Stool.  —  The  first  change  noticed  in  the 
dyspeptic  stool  is  the  increase  of  fat.  Often  the  stool  is 
quite  green  and  contains  small  pieces,  of  yellowish-white 
color,  which  vary  in  size  from  that  of  a  pin-head  to  the 
size  of  an  ordinary  pea.  Hitherto,  from  their  color,  they 
were  supposed  to  be  casein  lumps.  Wegscheider  has 
taught  us  that  they  consist  principally  of  fat.  Baginsky 
has  shown  that  large  colonies  of  bacteria  are  contained 
in  these  lumps  of  fat.  Frequently  they  are  so  numerous 
that  it  looks  as  though  the  stool  were  composed  only  of 
these  cheesy  lumps.  They  can  be  easily  differentiated 
from  real  casein  lumps  by  their  solubility  in  alcohol  and 
ether. 

Fat  Diarrhoea.— Biedevt  and  Demme  have  devoted 
considerable  attention  to  this  subject.71  In  some  children 
the  faeces  showed  50  to  60  per  cent,  of  fat,  whereas  the 
normal  percentage  in  ordinary  fasces  varied  from  13.9  per 
cent,  (which  is  the  normal  quantity),  according  to  Uffel- 
mann. 

Casein  is  not  nearly  as  common  an  ingredient  of 
fasces  as  is  commonly  supposed.  Casein  lumps  can  be 
seen  in  abundance  in  the  course  of  a  diarrhoea  during  an 
exclusive  diet  of  milk. 

Quantity  of  Fwces. — The  quantity  of  faeces  varies, 
but  it  has  been  found  that  100  grammes  of  milk-food  will 
produce  about  3  grammes  of  faeces,  according  to  Baginsky. 


71  See   Biedert:    "Fett-Dianhea/'   in  "Jahrbuch   fur   Kinderheil- 
kunde,"  1878. 


266  INFANT-FEEDING. 

This  is  a  vital  point,  but  I  have  found  it  very  difficult  to 
determine,  for  in  most  cases  the  napkins  of  the  infants 
are  soiled  with  urine  plus  the  fasces,  thus  adding  to  the 
gross  weight. 

Proteids.  ■ —  The  proteids  of  milk  are  so  thoroughly 
absorbed  that  only  small  traces  of  them  can  be  found  in 
the  fasces.  Normal  milk-fasces  contain  large  quantities  of 
bacteria,  but  chiefly  two  kinds,  previously  mentioned,  viz. : 
bacterium  lactis  aerogenes  (Escherich)  and  bacterium  coli 
commune.  Other  germs,  especially  those  of  the  proteo- 
lytic type  (i.e.,  those  that  render  gelatin  fluid),  are  not 
found  under  normal  conditions. 

Albuminous  decomposition  and  its  products — tyro- 
sin,  indol,  phenol,  and  skatol — are  not  found  in  milk-fasces. 
But  lactic  acid,  acetic  acid,  formic  acid,  and  other  fatty 
acids  are  present,  causing  the  acid  reaction. 

Saccharin  Ferment.- — Von  Jaksch  found  a  saccharin 
ferment  in  the  fasces  of  children. 

Peptonizing  Ferment. — Baginsky  found  a  peptonizing 
ferment  also  in  infantile  fasces. 

Escherich72  says:  "If  albuminous  decomposition  with 
very  foul  offensive  stools  exists,  these  articles  should  be 
withheld  from  the  diet  and  carbohydrates  given,  dextrin 
foods,  sugars,  and  milk.  If  acid  fermentation  is  present, 
with  sour,  but  not  offensive,  stools,  carbohydrates  are  to 
be  withheld  and  albuminous  foods  given,  such  as  animal 
broths,  bouillon,  peptones,  etc.  In  the  decomposition  of 
milk,  the  sugar  of  milk,  and  not  the  casein,  is  usually 
broken  up." 

Holt73  says:  "Regarding  the  exact  indications  accord- 
ing to  which  fat,  sugar,  and  proteids  of  milk  are  to  be 
varied,  much  remains  to  be  learned." 


72  "Jahrbuch  fur  Kinderheilkunde,"  "Beitrage  zur  Antiseptichen 
Behandlungs-methode  der  Magen-Darmkrankheiten  des  Sauglings- 
alters." 

73  "Artificial  Feeding,"  page  179. 


INFANT-STOOLS.  267 

Sugar  is  Too  Low. — If  the  sugar  is  too  low,  the  gain 
in  weight  is  apt  to  be  slower  than  when  furnished  in 
proper  amount. 

Sugar  in  Excess. — Symptoms  indicating  an  excess  of 
sugar:  Colic  or  thin,  green,  very  acid  stools,  sometimes 
causing  irritation  of  the  buttocks;  sometimes  there  is  re- 
gurgitation of  food  and  eructations  of  gas. 

Excess'  of  Fat. — Excess  of  fat  is  indicated  by  the  fre- 
quent regurgitation  of  food  in  small  quantities,  usually 
one  or  two  hours  after  feeding.  Sometimes  an  excess  of 
fat  causes  very  frequent  passages  very  nearly  normal  in 
appearance.  In  some  cases  the  stools  contain  small  round 
lumps  somewhat  resembling  casein,  but  really  masses  of 
fat.  This  has  already  been  mentioned  in  speaking  of  the 
differentiation  of  true  casein  curds  and  small  fat  lumps 
by  the  solubility  of  the  latter  in  alcohol  or  ether. 

Dry,  Pasty  Stools. — When  too  little  fat  is  given,  it  is 
indicated  by  hard,  dry,  pasty  stools,  and  usually  constipa- 
tion. This  can  be  easily  remedied  by  the  addition  of 
cream  three-fifths  of  which  is  fat.  Holt  speaks  against 
increasing  the  fat  above  4.5  per  cent,  in  infants  under  six 
months  old,  and  believes  we  should  not  go  above  4  per 
cent. 


CHAPTER  XL. 

Nathan   Straus  Milk-laboratories  and  Similar 
Charities. 

Since  1894,  through  the  generosity  of  the  Hon. 
Nathan  Straus,  pasteurized,  modified,  and  natural  milk 
has  been  supplied  from  laboratories  and  milk-depots  scat- 
tered throughout  New  York  City.  Some  of  these  are 
found  in  the  different  parks  of  the  crowded  portions  of 
our  city.  Hundreds  of  thousands  of  bottles  are  dispensed 
annually  in  New  York  and  in  neighboring  cities.  Thus, 
in  a  report  of  the  Board  of  Health  of  Brooklyn  for  the 
year  1895,  we  find  that  in  Brooklyn  42,739  bottles  were 
used. 

The  infant-mortality  has  certainly  been  lessened  dur- 
ing the  last  few  years  in  these  cities;  a  great  deal  of  it  is 
due  to  the  education  of  the  poorer  classes  living  in  tene- 
ment houses,  by  means  of  these  laboratories,  to  the  neces- 
sity of  using  boiled  food,  or  call  it  sterilized  milk,  and 
boiled  water.  There  are  other  factors  which  have  less- 
ened the  great  infant-mortality  in  New  York  City. 

Let  us  not  forget  the  difference  in  the  cleanliness  of 
the  streets  of  this  metropolis  due  to  the  energetic  work 
of  the  late  Colonel  Waring.  The  weeding  out  of  blocks 
of  tenement-houses,  and  the  substitution  of  small  parks 
in  the  heart  of  the  tenement-district  must  certainly  be 
healthful.  Whoever  studies  the  development  of  rickets 
will  find  that  it  is  not  only  the  feeding,  which  is  the 
prime  factor,  but  it  is  the  environment,  the  faulty  dwell- 
ing, with  its  foul  air  and  general  unsanitary  condition, 
that  contribute  to  the  poisoning  of  the  air  breathed  by 
the  infant;  this  poisoning  is  as  distinct  a  toxcemic  con- 
dition as  it  would  be  if  a  poison  were  injected  directly 
(2G8) 


MILK  LABORATORIES.  269 

into  the  body.     Faulty  food,  be  it  breast-milk  or  cows' 
milk,  is  the  prime  factor. 

Having  been  on  continuous  duty  in  the  children's 
service  of  one  of  the  largest  clinics  in  this  city  for  over 
ten  years,  the  author  has  noted  many,  many  changes.  In 
recent  years  the  large  number  of  excursions,  notably  the 
St.  John's  Guild,  which  gives  an  excursion  every  day 
during  the  hot  summer  months  to  the  poor  destitute 
children  of  our  city,  has  certainly  added  to  the  health  of 
many  little  ones.  There  are  also  numerous  sectarian  ex- 
cursions; so,  for  example,  there  is  a  Hebrew  sanitarium 
giving  excursions  to  Rockaway  every  day  during  the 
summer.  Then  there  are  numerous  church  excursions 
and  charitable  funds,  notably  the  New  York  Herald  Ice 
Fund,  all  of  which  have  a  tendency  to  invigorate  the 
lives  of  these  poor  infants,  and  in  this  manner  they  can 
withstand  the  terrible  heat  of  the  summer  months,  and 
survive  it.  The  sanitary  vigilance  of  the  Board  of  Health 
of  New  York  City  has  certainly  improved  the  sewage 
and  drainage,  looked  after  the  water-supply,  and  certainly 
benefited  the  city.  These  factors  must  be  taken  into 
account  in  studying  the  mortality  and  the  population. 
The  blessing  for  New  York  City  will  consist  in  giving 
it  a  pure,  clean,  and  rich  milk  in  which  the  stable,  and 
cow,  and  milker's  hands  and  all  utensils  are  absolutely 
sterile.  I  cannot  emphasize  too  strongly  that  the  ideal 
milk  of  the  future  will  not  be  sterilized  milk,  not  pasteur- 
ized milk,  but  will  be  pure,  raw  milk.  Nature,  in  the 
human  breast,  supplies  her  infants  with  raw  milk  at  body- 
temperature;  why  must  we  feed  our  infants  with  boiled 
or  steamed  milk,  especially  so,  when  chemists  have  taught 
us  that  chemical  changes  take  place  in  boiled  as  well  as 
in  sterilized  milk,  rendering  the  milk  more  indigestible 
than  it  was  in  its  raw  state? 

A  vital  point  to  remember  is  that  the  milk,  when 
drawn  from  the  cow,  must  be  quickly  cooled  and  must  not 
be  allowed  to  reach  a  temperature  above  50°  F.  until  used. 


270  INFANT-FEEDING. 

Such  milk  will  not  permit  the  development  of  bac- 
teria dangerous  to  health. 

Rapid  cooling,  then, — to  repeat  again, — is  as  impor- 
tant as  the  most  absolute  assurance  of  cleanliness  and  ster- 
ility of  every  utensil  brought  in  contact  with  milking — so 
necessary  to  avoid  introduction  of  filth  or  bacteria. 


CHAPTER  XLI. 


Colic. 


Colic  is  one  of  the  most  frequent  causes  of  crying  in 
children.  They  not  only  cry  loudly,  but  will  suddenly 
shriek,  and  when  put  to  sleep  will  awaken  with  a  sudden 
start,  and  cry  loudly.  The  legs  are  usually  flexed  or  they 
will  move  their  legs  back  and  forth,  or  up  and  down. 
They  will  seem  to  bend  the  body  on  itself.  These  attacks 
are  usually  associated  with  constipation;  hence,  it  is  a 
good  plan,  when  the  child  is  restless  and  utters  a  painful 
cry,  to  see  if  the  bowels  have  moved.  It  is  well  known 
that  this  colic  may  be  as  well  associated  with  diarrhoea. 
The  origin  of  all  colic  is  certainly  the  stomach.  When 
dyspeptic  conditions,  arising  from  undigested  particles  of 
food  in  the  stomach,  exist,  then  fermentation,  resulting 
in  gas-formation,  is  the  result.  Colic  is  frequently  known 
by  the  terms  of  "meteorismus  or  tympanites,"  but  in  the 
latter  conditions  the  abdomen  is  greatly  distended,  and 
there  is  a  permanent  enlargement  of  it.  Borborygmus  can 
usually  be  made  out,  if  the  ear  is  applied  to  the  abdomen. 
The  vast  majority  of  cases  of  colic  have  their  seat  in  the 
intestine,  and  can  be  relieved  very  quickly. 

Worms  (ascarides)  have  been  known  to  cause  colic. 
Besides,  when  there  is  a  general  loss  of  tone  on  the  part 
of  the  muscular  layers  in  the  walls  of  the  intestine,  colic 
will  frequently  result.  Jacobi  believes  that  colic  can  be 
caused  by  chronic  peritonitis  resulting  in  adhesions  or 
local  changes  in  the  walls  of  the  intestine  that  will  pro- 
duce local  contractions  or  dilatations. 

An  excellent  preparation  to  relieve  colic  is  calcined 
magnesia,  or  milk  of  magnesia,  made  by  Phillips.  Hare's 
"System  of  Medicine"  contains  an  article  by  Stewart  ad- 

(271) 


272  INFANT-FEEDING. 

vocating  its  use.  It  has  served  the  writer  very  well  espe- 
cially in  young  infants,  where  acidity  was  prevalent.  A 
half-teaspoonful  several  times  a  day  was  enough  in  some 
cases,  while  others  required  several  teaspoonfuls  during 
the  day.  It  is  valuable  where  constipation  exists,  and  can 
be  added  to  the  bottle  of  food. 

The  treatment  of  colic  is  simple  when  the  cause  is 
known.  The  quickest  method  of  relieving  colic  is  to 
give  an  enema  of  soap  and  water  or  of  warm  chamomile- 
tea.  I  usually  take  an  ounce  of  German  chamomile- 
flowers  and  steep  them  in  a  quart  of  boiling  water  for 
from  ten  to  fifteen  minutes,  then  strain.  The  injection  is 
to  be  given  in  the  same  manner  as  will  be  described  in 
detail  in  the  chapter  on  constipation.  My  method  is  to 
allow  1  or  2  pints  of  chamomile-tea  at  a  temperature  of 
100°  to  110°  F.  (no  hotter)  to  flow  slowly  into  the  rectum, 
and  by  all  means  the  colon.  When  the  colon  is  thor- 
oughly flushed  with  this  warm  tea,  and  emptied  of  its 
fseces,  it  is  usual  for  the  attack  of  colic  to  cease.  In  addi- 
tion to  washing  the  colon,  it  is  a  good  plan  to  apply  a 
small  bag  of  either  chamomile-flowers  or  slippery-elm 
bark,  or  ground  flaxseed  meal.  To  do  this,  I  make  a  bag 
of  cheese-cloth,  capable  of  holding  from  1  to  2  ounces, 
and  then  fill  it  with  one  of  the  above-mentioned  ingre- 
dients; sew  the  bag  shut  when  filled,  and  heat  it  before 
applying  to  the  abdomen.  Several  of  these  bags  can  be 
made  and  kept  in  readiness,  so  that  they  can  be  applied 
quickly.  It  is  a  good  plan  to  have  one  heating  on  the 
stove,  while  another  is  on  the  abdomen.  These  little  bags 
are  very  grateful,  and  we  are  frequently  rewarded  by 
having  the  infant  not  only  expel  wind  shortly  after  they 
are  applied,  but  also  frequently  fall  asleep. 

MASSAGE. 

During  an  attack  of  colic  gentle  massage  with  warm 
sweet  oil  or  melted  vaselin  or  lard  will  certainly  be  very 
comforting  to  the  child.     My  plan  is  to  take  a  bottle  of 


colic.  273 

oil,  warm  it  by  placing  it  in  a  kettle  of  warm  water,  and 
then  to  pour  it  on  the  abdomen.  The  distended  abdomen 
should  then  be  thoroughly  kneaded,  and  the  gas  expelled. 
Then  the  warm  applications  mentioned  above  can  be  ap- 
plied. 

DRUG    TREATMENT. 

If  the  colic  originated  from  a  fermentative  dyspep- 
sia, then  treatment  must  be  directed  to  the  stomach.  For 
this  purpose  antifermentatives,  like  the  mistura  rhei  et 
sodas,  should  be  given  in  doses  of  1/2  to  1  teaspoonful, 
diluted  with  water,  every  two  or  three  hours  until  there 
is  a  thorough  evacuation.  Very  good  results  will  be 
found,  after  the  bowel  has  been  cleaned  with  the  quart 
of  chamomile-tea  previously  mentioned,  by  administering 
from  5  to  10  grains  of  bismuth;  I  prefer  to  use  beta- 
naphtol  or  the  subnitrate;  a/2-grain  doses  of  resorcin  will 
also  be  found  useful.  Paregoric,  in  doses  of  15  drops  to 
1/2  teaspoonful  should  be  administered  with  great  cau- 
tion to  children  of  six  months  or  older.  It  is  understood 
that  no  physician  will  forget  the  danger  of  giving  re- 
peated doses  of  paregoric  or  permitting  the  same  to  be 
administered  by  incompetent  people  not  aware  of  the 
dangers  of  the  drug  habit.  The  author  has  not  only  seen 
distinct  opium  poisoning  follow  the  use  of  paregoric,  but 
has  also  had  occasion  to  see  the  distinct  opium  habit  in 
very  young  children.  This  was  reported  by  the  author 
in  a  paper  read  before  the  ISTew  York  County  Medical 
Society,  January  22,  1894,  which  was  published  in  ex- 
tenso  in  the  Medical  Record  of  February  17,  1894.  For 
an  infant  during  the  first  few  months,  it  is  hardly  safe 
to  give  more  than  5  drops  of  paregoric,  repeated  in  an 
hour  if  there  is  no  relief.  Another  drug  that  has  served 
the  author  very  well  is  Hoffmann's  anodyne  in  doses  of 
from  1  to  5  drops,  repeated  in  an  hour  if  necessary.  For 
an  infant  up  to  two  months  1  drop  per  dose;  from  two 
to  four  months,  2  drops  per  dose;    four  to  six  months,  3 


274  INFANT-FEUDING. 

drops;  six  to  nine  months  and  until  one  year  of  age,  4 
drops;  children  from  one  to  two  years,  5  drops.  This  is 
to  be  given  in  a  teaspoonful  of  sterilized  water.  Another 
valuable  drug,  and  one  that  is  to  be  given  cautiously,  and 
in  the  same  doses  as  Hoffmann's  anodyne,  is  spirit  of 
chloroform;  never  should  more  than  from  1  to  4  drops 
be  given  to  a  child  up  to  one  year  of  age,  and  younger 
children  less  in  proportion.  I  cannot  favor  the  admin- 
istration of  nauseating  or  foul-smelling  drugs,  such  as 
asafcetida.  We  must  try  to  cater  to  an  infant's  taste, 
especially  so  when  in  pain. 

THE    USE    OF    SUGAR. 

When  colic  is  caused  by  an  excess  of  sugar,  there  will 
be  considerable  eructations  of  gas,  and,  frequently,  small 
quantities  of  food  will  be  regurgitated. 

The  stools,  when  an  excess  of  sugar  is  given,  are  thin 
and  greenish,  smell  very-  acid,  and  usually  produce  a  red- 
dened excoriation  of  the  buttocks  afound  the  anus. 

When  children  show  a  tendency  to  the  development 
of  gas  and  have  constant  recurring  colic,  my  plan  is  to 
discontinue  the  use  of  sugar  until  such  time  as  this 
fermentation  is  absent.  To  sweeten  the  food  I  use  small, 
saccharin  tablets,  1  grain  being  ample  to  sweeten  1  pint 
of  food.  When  there  is  a  tendency  to  constipation,  it  is 
possible  not  only  to  sweeten  the  food,  but  also  to  modify 
this  constipation  by  adding  1  teaspoonful  of  pure  glycerin 
to  each  bottle  of  food  prepared.  A  teaspoonful  of  malt- 
extract  will  also  relieve  constipation. 

EXCESS    OF    PKOTEIDS. 

A  careful  observation  of  the  stools  would  easily  show 
whether  the  albuminoids  are  in  excess,  for  they  are  usually 
present  in  the  form  of  curds.  This  condition  is  usually 
associated  with  constipation,  and  the  indication  would  be 
to  cut  down  the  quantity  of  curd  administered. 


CHAPTER  XLIL 

Constipation. 

To  consider  the  cause  of  constipation  during  the 
nursing  period  let  us  first  look  into  the  mechanical  cause: 
Concetti,74  in  a  very  elaborate  article,  gives  the  various 
anatomical  reasons  for  constipation.  He  states  that 
Huguier,  in  the  Bulletin  cle  V  Academie  de  Medecine,  had 
reported  this  same  pathological  condition  several  years 
prior  to  Jacobi,  of  New  York.  Thus,  Huguier  advises, 
as  a  practical  point,  that  when  a  colotomy  was  to  be  per- 
formed in  an  infant  it  would  be  wiser  to  perform  the 
same  on  the  right  side  rather  than  on  the  left.  He  stated 
that  it  was  much  easier,  owing  to  the  greater  number  of 
flexures,  to  reach  the  same  by  operating  on  the  right  side 
in  cases  of  atresia  of  the  anus.  Concetti  further  states 
that  Jacobi,  in  1868,  reported  in  the  American  Journal 
of  Obstetrics  an  elaborate  article,  which  has  since  appeared 
in  the  "Therapeutics  of  Infancy  and  Childhood"  (A. 
Jacobi,  1887),  giving  the  anatomical  reasons  in  detail. 
They  are  well  worth  noting: — 

The  embryonic  intestine  is  formed  in  separate  di- 
visions. There  is  no  ascending  colon  up  to  the  fourth  or 
fifth  month  of  foetal  life.  It  is  very  short  in  the  mature 
newborn.  Despite  this,  the  large  intestine  of  the  mature 
foetus  is  longer  in  proportion  than  that  of  the  adult.  It 
is  three  times  as  long  as  the  body  of  the  foetus,  while 
it  is  only  twice  as  long  in  the  adult. 

There  is  the  same  disproportion  with  regard  to  the 
length  of  the  small  intestine.  The  small  intestine  of  the 
foetus  in  the  ninth  month  is  twelve  times  as  long  as  its 

74Archiv  fur  Kinderheilkunde,  vol.  xxvii,  1899. 

(275) 


276  INFANT-FEEDING. 

body.    The  small  intestine  of  the  adult  is  only  eight  times 
as  long  as  the  body. 

The  colon  ascendens  being  very  short,  the  surplus  of 
length,  particularly  as  the  transverse  colon  also  is  not 
long,  belongs  to  the  descending  colon,  and  especially  to 
the  sigmoid  flexure.  Drandt  found  it  between  8  and  24 
centimetres  in  length,  averaging  from  14  to  20.  I  have 
seen  a  case  in  which  it  was  30  centimetres  long. 

As  the  pelvis  is  very  narrow,  the  great  length  of  the 
lower  part  of  the  large  intestine  is  the  cause  of  multiple 
flexures,  instead  of  the  single  sigmoid  flexure  of  the  adult. 
Thus  it  is  that,  now  and  then,  two  or  even  three  flexures 
are  found,  and  to  such  an  extent  that  one  of  them  may 
be  found  to  extend  as  far  as  the  right  side  of  the  pelvis. 
Cruveilhier  and  Sappey  speak  of  this  position  of  the  lower 
part  of  the  intestine  in  the  right  side  of  the  pelvis  as 
an  anomaly.  Huguier  finds  it  on  the  right  side  of  the 
body  in  the  majority  of  cases.  Others  only  occasion- 
ally, although  they  admit  the  great  length  of  the  sig- 
moid flexure.  In  common  with  Huguier,  who  even 
proposes  to  operate  for  artificial  anus  in  the  right  side,  I 
have  found  one  of  the  flexures  on  the  right  side  many 
times. 

The  great  length  of  the  large  intestine  and  the  multi- 
plicity of  its  flexures  are  of  great  functional  importance. 
At  all  events,  they  retard  the  movement  of  the  intestinal 
contents,  facilitate  the  absorption  of  fluids,  and  thus  the 
faeces  are  rendered  solid.  .When  this  length  is  developed 
to  an  unusual  extent,  constipation  is  the  natural  result. 
In  the  American  Journal  of  Obstetrics,  August,  1869,  I 
have  described  two  cases  in  which  the  descending  colon 
was  so  long  that  the  diagnosis  of  imperforate  rectum  was 
made.  In  one  of  them  the  operation  for  artificial  anus 
was  performed.  Such  cases  and  such  errors  are  certainly 
very  rare ;  still  there  are  those  in  which  normal  anatomical 
conditions  will  lead  to  incidents  of  great  pathological  im- 
portance. 


CONSTIPATION".  277 

Other  cases  of  constipation  in  the  infant  may  be 
classed  under  four  heads: — - 

First. — The  intestinal  mucus  is  deficient  or  too  vis- 
cid. Such  is  the  case  in  febrile  conditions,  now  and  then 
in  chronic  intestinal  catarrh,  and  also  when  there  is  too 
much  perspiration  and  secretion  of  urine. 

Second.  —  Improper  condition  of  food.  A  super- 
abundance of  casein,  particularly  cows'  casein;  of  starch; 
the  absence  of  sugar,  and  the  administration  of  astrin- 
gents and  iron. 

Third. — Incomplete  peristalsis,  such  as  exists  in  the 
rachitic  debility  of  the  muscular  layer,  in  the  muscular 
debility  dependent  upon  sedentary  habits  and  peritonitis, 
intestinal  atrophy,  and  hydrocephalus. 

Fourth. — Mechanical  obstruction.  Cystic  tumors  in 
the  intestine.  There  is,  further,  intussusception  and  twist- 
ing of  the  intestine,  incarcerated  hernia,  even  umbilical 
hernia,  hardened  faeces,  and  imperforations. 

In  all  these  cases  the  diagnosis  should  not  be  made 
without  manual  examination.  In  most  of  the  cases  the 
abdomen  is  inflated,  though  it  be  painless.  The  fasces 
come  away  in  small,  hard  lumps  or  in  large  masses.  The 
liver  and  spleen  are  displaced.  The  liver  may  be  so 
turned  that  a  part  of  its  posterior  surface  comes  forward. 
The  abdominal  veins  are  enlarged  to  such  an  extent  that 
they  form  circles  around  the  umbilicus,  similar  to  what 
is  seen  in  hepatic  cirrhosis.  These  children  lose  their 
appetite,  sometimes  vomit,  and  the  irritation  produced  by 
the  hardened  masses  in  the  intestinal  canal  may  be  such 
as  to  finally  result  in  diarrhoea,  which,  however,  is  not 
always  sufficient  to  empty  the  tract. 

There  is,  besides,  an  apparent  constipation,  which 
should  not  be  mistaken  for  any  of  the  above  varieties. 
Now  and  then  a  child  will  appear  to  be  constipated,  have 
a  movement  every  two  or  three  days,  and  at  the  same 
time  the  amount  of  fasces  discharged  is  very  small.  This 
apparent  constipation  is  seen  in  very  young  infants  rather 


278  INFANT-FEEDING. 

than  in  those  of  more  advanced  age.  Snch  children  are 
emaciated,  sometimes  atrophic.  They  appear  to  be  con- 
stipated because  of  lack  of  food,  and  not  infrequently 
this  apparent  constipation  is  soon  relieved  by  a  sufficient 
amount  of  nourishment. 

Constipation  resulting  from  a  superabundance  of 
starch  in  the  food  is  easily  cured  by  the  withdrawal  of 
the  latter. 

Constipation  produced  by  too  much  casein  in  the  food 
will  be  relieved  by  diminishing  its  quantity.  The  propor- 
tion of  casein  in  the  food  of  infants  should  never  be  more 
than  1  per  cent.  Besides,  this  amount  of  casein  ought 
to  be  copiously  mixed  with  a  glutinous  decoction. 

Infants  that  have  been  fed  on  starchy  food  or  even 
such  cereals  as  barley,  should  have  oatmeal  substituted 
for  the  barley. 

Constipation  depending  on  lack  of  sugar  is  very  often 
speedily  relieved  by  increasing  the  quantity  of  sugar  in 
the  food.  This  is  the  case,  not  only  in  artificial  feeding, 
but  also  when  the  children  are  fed  normally  on  breast- 
milk.  Such  mothers'  milk  as  is  white  and  dense,  and 
contains  a  large  amount  of  casein,  is  made  more  digestible, 
and  will  produce  better  evacuations,  when  a  piece  of  loaf- 
sugar  dissolved  in  tepid  water  is  given  immediately  before 
nursing. 

As  there  is  frequently  a  large  excess  of  acid  in  the 
intestine,  magnesia  with  or  without  rhubarb,  will  fre- 
quently relieve  the  acidity  and  cause  a  movement  of  the 
bowels. 

In  a  previous  section  on  "Cream"  I  have  already 
spoken  of  the  deficiency  of  fat,  which  is  one  of  the  most 
frequent  causes  of  constipation.  Hence,  in  an  infant 
nursing  at  the  breast  it  is  wise  to  give  the  child  a  tea- 
spoonful  of  raw  cream  immediately  before  taking  the 
breast  to  correct  the  constipation.  Cream  consists  of  so 
much  fat  that  in  this  manner  we  add  fat  directly  to  our 
food.      This  is  the  secret  of  success   attained  by  some 


CONSTIPATION.  £79 

authors  when  they  advise  giving  codliver-oil,  butter, 
olive-oil,  or  fried  bacon  to  very  young  children.  Each 
one  desires  to  remedy  the  deficiency  of  fat  in  his  own 
particular  manner. 

A    DBINK    OF    WATEK. 

From  infancy,  when  the  child  is  but  a  few  days  old, 
we  should  make  it  a  rule  to  give  it  a  drink  of  water;  thus 
a  very  small  infant  during  its  first  week  can  be  given  two 
to  three  teaspoonfuls  of  boiled  water  during  the  day.  A 
safe  plan  is  to  give  this  drink  of  water  when  it  is  not 
time  for  feeding,  and  if  the  child  appears  restless.  It  is 
understood  that  we  must  first  satisfy  ourselves  that  the 
child  has  not  had  a  stool,  is  not  lying  in  a  soiled  napkin, 
and  that  other  conditions — such  as  colic — do  not  cause 
uneasiness  in  the  baby.  When  a  child  is  several  months 
old,  the  quantity  of  water  can  be  increased  from  teaspoon- 
fuls to  as  _  many  wineglassfuls.  Frequently  have  I  noted 
the  disappearance  of  a  continued  constipation  after  giving 
an  infant  its  "drink  of  water"  regularly. 

IMMEDIATE    RELIEF    OF    CONSTIPATION. 

A  rule  that  I  have  always  followed,  and  one  that  I 
lay  stress  upon,  is  never  to  allow  a  child  to  retire  at  night 
without  having  had  a  movement  of  the  bowels  during  the 
day.  The  reason  for  this  is  plain;  not  only  will  the 
accumulated  fasces  and  gas  cause  flatulence,  colic,  and 
uneasiness,  but  this  constant  distension  of  the  bowels  will 
dilate  the  intestines  to  such  a  degree  that  frequently  a 
permanent  pendulous  belly  remains. 

My  plan  is  to  order  an  injection  of  a  half -tumbler 
of  ordinary  glycerin  mixed  with  a  pint  of  warm  water, — 
temperature,  100°  F., — and  to  allow  this  quantity  to  flow 
into  the  rectum  by  using  a  fountain-syringe,  the  end  of 
which  has  the  smallest  infants'  rectal  nozzle.  In  this 
manner  we  have  a  rapid  emptying  of  the  rectum  and 


280  INFANT-FEEDING. 

colon,  and  can  be  assured  of  temporary  and  possibly  per- 
manent relief.  It  is  not  absolutely  vital  to  use  glycerin 
and  water,  for  a  similar  result  can  be  obtained  if  we  make 
soap-water  by  rubbing  up  a  piece  of  Castile  soap  with 
a  pint  of  warm  water,  or  using  glycerin  soap  with  the 
equal  quantity  of  water,  if  the  latter  soap  can  be  pro- 
cured. 

Continued  Use  of  Enema. — In  obstinate  cases  it  is 
well  to  slip  a  soft-rubber  rectal  tube  over  the  nozzle,  and, 
having  anointed  the  rubber  tube  with  vaselin  or  glycerin, 
the  same  can  be  pushed  slowly  into  the  rectum,  then  allow 
about  half  a  pint  of  water  to  flow  into  the  rectum,  which 
will  distend  it  gradually,  and,  by  simply  pushing  the  tube 
farther  into  the  colon,  we  can  allow  the  balance  of  1  pint 
or  more  to  flow  directly  into  the  colon.  The  continued 
use  (daily)  of  these  enemas  is  not  fraught  with  danger; 
on  the  contrary,  these  rectal  injections  can  be  used  for 
months.  In  safe  hands,  if  the  mother  or  nurse  is  intel- 
ligent, there  should  be  not  only  no  injury,  but  positive 
good,  from  its  continued  use. 

REMOVAL    OF    SCYBALA. 

Hardened  round  balls  or  fragments  of  fseces  will  fre- 
quently be  caused  when  the  stool  remains  very  long  in 
the  colon,  or  when  the  sigmoid  flexure  has  an  unusual 
length;  in  such  instances  the  injection  of  either  * /2  pint 
of  lukewarm  sweet  oil  or  glycerin  will  soften  these  scybala 
and  aid  in  their  expulsion.  At  times  these  balls  will  be  as 
hard  as  marbles,  and  may  require  the  aid  of  a  small  scoop 
(a  very  small  teaspoon  will  do)  to  aid  in  their  removal. 

DRUG    TREATMENT. 

A  great  many  drugs  are  indicated  and  contra-indi- 
cated in  the  treatment  of  constipation.  The  intelligent 
practitioner  does  not  desire  merely  one  movement  of  the 
bowels,  brought  about  by  drugs,  but  seeks  rather  to  use 


Fig.  45.— Funnel-shaped  Depression  of  Sternum.  Rachitic  Ky- 
phosis. Deformity  of  Spine.  Picture  also  Illustrates  Ra- 
chitic Square  Head.  (From  Author's  Service  in  Children's 
Department  of  German  Poliklinik.) 


CONSTIPATION.  281 

such  therapeutic  measures  as  will  give  a  permanent  cure. 
My  choice  of  drugs  is  the  following: — 

I£  Ext.  cascara  sagrada  fl.,  §j. 
Glycerin,  3j. 

Mix.  Twenty  drops  of  the  above  mixture  in  a  teaspoonful  of 
water  three  times  a  day,  for  children  about  three  months  old.  At 
the  age  of  six  months,  double  the  dose,  or  20  drops  three  times  a 
day.    At  the  age  of  one  year  a  teaspoonful  three  times  a  day. 

Another  valuable  preparation  is  malt-extract  with  cas- 
cara, in  teaspoonful  closes,  once  or  twice  a  day. 

My  plan  is  to  give  the  first  dose  in  the  morning  be- 
fore the  feeding,  and  note  the  result.  If  the  bowels  move 
by  noon-time  then  I  discontinue  the  dose  at  noon,  and 
give  a  second  dose  in  the  evening.  If,  however,  there  is 
no  effect  by  noon-time,  then  I  continue  my  second  dose, 
and  follow  with  my  third  dose  in  the  evening.  Thus,  it 
will  be  apparent  that,  if  one  dose  answers  for  the  day, 
then  we  should  discontinue  the  medicine  for  that  day, 
but  commence  again  on  the  following  day,  and  keep  up 
this  form  of  drug  treatment  until  it  is  apparent  that  the 
bowels  are  not  as  sluggish  in  their  action  as  before.  An- 
other drug  which  has  been  one  of  my  stand-bys  for  many 
years  is  mix  vomica.  I  give  1  drop  of  the  tincture 
of  nux  vomica  in  a  teaspoonful  of  sterile  water  three 
times  a  day,  for  an  infant  up  to  one  year  of  age.  Chil- 
dren of  two  years  I  give  2  drops  three  times  a  day.  From 
three  to  six  years,  3  drops  three  times  a  day.  Six  to  ten 
years,  4  drops  three  times  a  day.  Ten  to  fifteen  years  of 
age,  5  drops  three  times  a  day.  ]STux  vomica  is  always 
to  be  administered  on  an  empty  stomach;  in  other  words, 
before  feeding.  Another  valuable  drug  is  rhubarb  in  the 
form  of  the  aromatic  syrup  of  rhubarb.  From  1/2  to  1 
teaspoonful  once  or  twice  a  day,  repeated  every  two  days, 
will  frequently  afford  relief. 

Powdered  rhubarb  and  magnesia,  given  in  teaspoon- 
ful doses  to  very  young  children,  is  one  of  the  best  laxa- 


282  INFANT-FEEDING. 

tives  and  antifermentatives  that  we  possess.  It  is  espe- 
cially indicated  for  the  relief  of  colic. 

Citrate  of  magnesia,  given  in  wineglassful  doses  to 
children  over  one  year  of  age  once  or  twice  a  day,  can 
also  be  recommended. 

In  atonic  conditions  of  the  bowels  depending  on  gen- 
eral weakness,  strychnine,  given  in  V200  grain  doses  twice 
a  day,  will  be  found  useful.  This  may  or  may  not  be  com- 
bined with  iron. 

The  infusion  of  senna-leaves  is  made  by  boiling  a 
heaping  teaspoonful  of  ordinary  senna  in  a  teacupful  of 
boiling  water  for  fifteen  minutes,  straining,  and  when 
cool  adding  1  tablespoon  of  glycerin  to  5  tablespoons  of 
this  infusion  of  senna.  This  quantity  to  be  adminis- 
tered in  three  doses  at  intervals  of  four  or  five  hours. 
In  some  instances  the  addition  of  syrup  of  manna  will 
be  found  advantageous  in  sweetening  the  infusion  of 
senna. 

Certain  drugs  should  not  be  given.  Of  these  castor- 
oil  may  serve  as  a  type.  The  constipating  effect  following 
the  use  of  castor-oil  is  so  well  known  that  this  drug  is 
indicated  when  we  wish  to  cleanse  the  stomach  and  bowels 
and  remove  stagnant  food,  as,  for  example:  in  fermenta- 
tive dyspepsia  accompanied  by  diarrhoea.  Thus,  we  not 
only  have  an  effective  movement,  but  a  constipating  effect 
following  the  same.  The  use  of  drastic  cathartics — such 
as  scammony,  elaterin,  or  podophyllin — should  not  be 
thought  of  in  the  treatment  of  infants  and  children. 
Very  rarely  do  I  use  aloes,  owing  to  its  offensive  taste. 
It  is  understood  that  calomel  is  only  to  be  given  when 
we  wish  to  cleanse  and  produce  an  antiseptic  effect  in 
the  intestine;  for  the  treatment  of  constipation  per  se, 
calomel  is  entirely  out  of  place. 

Suppositories. — Among  those  most  commonly  used 
are  suppositories  of  the  glycerin  and  gluten  type.  Gluten 
suppositories  are  made  by  the  Health  Food  Company,  of 
New  York  City.     Most  suppositories  in  the  market  are 


Fig.  46. — Rickets,  showing  Beaded  Ribs.  Breast-Fed  Infant 
with  Poor  Hygienic  Conditions  and  Delicate  Mother. 
(From  Children's  Service  of  German  Poliklinik.) 


CONSTIPATION".  283 

entirely  too  large,  and  frequently  must  be  cut  into  halves 
and  quarters.  The  suppository  made  by  Parke,  Davis  & 
Co.  has  served  the  author  very  well.  It  should  be  dis- 
tinctly understood  that  a  suppository  is  to  be  used  in  the 
evening  for  the  same  relief  as  we  desire  from  the  injection 
or  enema  previously  mentioned.  Neither  the  suppository 
nor  the  injection  should  be  used  with  the  idea  of  curing 
a  constipation. 

MASSAGE. 

Continued  kneading  of  the  abdomen  with  the  aid  of 
vaselin  or  oil  will  be  found  serviceable,  and,  if  properly 
done,  will  provoke  an  action  of  the  bowel.  Thus  it  is 
that  rubbing  the  abdomen  with  castor-oil  has  frequently 
been  recommended  in  the  treatment  of  constipation;  the 
effect  supposed  to  be  due  to  the  castor-oil  is,  in  reality, 
due  to  the  massage,  and  to  nothing  else.  "When  massage 
is  used,  it  should  be  continued  from  five  to  ten  minutes 
every  day  for  one  month,  morning  and  evening.  This  will 
certainly  aid  and  stimulate  peristalsis,  and  ultimately  tone 
the  muscles  and  cure  the  constipation. 

ELECTRICITY. 

This  is  very  valuable  to  stimulate  peristalsis.  The 
faradic,  galvanic,  or  static  current  can  be  used.  For  the 
general  practitioner  the  use  of  the  galvanic  current,  five 
to  ten  cells,  is  sufficient.  The  negative  pole  (cathode) 
should  be  applied  in  the  rectum,  and  the  positive  pole, 
which  produces  peristaltic  waves,  should  be  applied  over 
the  ascending,  descending,  and  transverse  colon.  Local 
contractions  result  from  the  negative  pole.  A  gentle 
faradic  current  applied  over  the  spine  and  the  abdomen 
will  answer  if  used  for  several  minutes  in  the  absence 
of  the  galvanic  current.  Galvanic  electricity  should  be 
used  every  day;  frequently  months  are  required  to  insure 
a  cure,  in  conjunction  with  the  medicinal  and  dietetic 
treatment. 


284  INFANT-FEEDING. 

DIETETIC    TREATMENT, 

We  have  previously  mentioned  the  value  of  cream, 
and  the  addition  of  water  for  the  treatment  of  consti- 
pation. In  bottle  babies  it  is  well  to  remember  that  oat- 
meal-water and  sago-water  should  be  used  when  constipa- 
tion exists.  Under  no  condition  should  barley  or  rice  be 
given,  as  the  latter  will  simply  increase  the  constipation. 
Older  children  should  be  given  fruit,  baked  apples, 
peaches,  prunes,  grapes,  and  oranges,  and  avoid  pears. 
Buttermilk  will  be  found  serviceable,  as  well  as  koumiss, 
for  the  relief  of  constipation.  Sugar  (cane-sugar)  will 
be  found  quite  serviceable,  when  added  to  water,  for 
the  relief  of  constipation  in  nursing  or  bottle-fed  babies. 
Thus,  a  good  plan,  according  to  Jacobi,  is  to  give  a  small 
piece  of  loaf-sugar  dissolved  in  water  immediately  before 
nursing,  and  to  substitute  and  use  cane-sugar  instead  of 
milk-sugar  for  bottle-fed  babies. 

Having  regulated  the  diet  and  excluded  fresh  bread, 
cakes,  pies,  pastries,  macaroni,  and  other  floury  foods,  we 
should  insist,  in  children  over  two  years  of  age,  on  eating- 
all  green  vegetables  with  the  exception  of  cabbage,  beans, 
turnips,  potatoes,  and  corn.  Thus,  celery,  spinach,  green 
peas,  asparagus,  and  cauliflower  are  recommended. 

EXERCISE. 

What  massage  is  for  a  young  infant  exercise  is  for 
an  older  child.  Thus,  it  is  apparent  that  atonic  condi- 
tions can  best  be  relieved  by  combining  the  dietetic  and 
medicinal  treatment  with  out-of-door  exercise.  Children 
should  be  permitted  to  romp  about  and  walk  and  play 
out  of  doors,  but  not  to  a  point  approaching  fatigue. 
Older  children  will  find  bicycle  exercise  or  horseback- 
riding  decidedly  beneficial.  It  is  important,  however,  to 
regulate  the  amount  of  such  exercise,  and  thus  it  is  ap- 
parent that  it  is  the  physician's  duty  to  tell  the  mother 
or  nurse  just  how  long  a  child  should  be  permitted  to 


Fie-.  47. — Showing  Rachitic  Beaded  Ribs  on  Left  Side  of  Thorax. 


CONSTIPATION.  285 

exercise.  It  would  seem  that  one-half  hour  twice  a  day 
is  ample  to  arrive  at  beneficial  results.  Overindulgence 
in  such  sports  will  frequently  result  in  rupture  and  pro- 
duce heart-strain.  In  cardiac  lesions,  in  asthmatic  con- 
ditions, if  children  suffer  with  whooping-cough,  and  in 
tuberculous  conditions  such  exercises  must  not  be  allowed. 

HYGIENIC    TREATMENT. 

We  should  insist  on  proper  ventilation  of  a  child's 
sleeping-room  at  night,  and  it  is,  therefore,  advised  that 
the  window  be  left  open  a  few  inches.  This  is  not  fraught 
with  danger;  on  the  contrary,  it  is  healthful  and  bene- 
ficial to  allow  children  to  play  in  the  open  air  all  day, 
and  naturally  to  shut  them  up  in  poorly  ventilated  apart- 
ments at  night  is  simply  inviting  both  throat  and  lung 
trouble.  In  addition  to  proper  ventilation,  bathing  in 
cool  water  or  lukewarm  water,  followed  by  an  abdominal 
spray  or  a  douche  directed  against  the  stomach  and  bow- 
els, will  be  found  advantageous  in  the  correction  of  this 
ailment.  Following  the  bath,  friction  with  a  good,  coarse, 
Turkish  towel  will  be  found  useful.  My  preference  has 
always  been  for  a  lukewarm  bath,  followed  by  a  cold 
douche  for  a  few  moments,  every  morning,  and  then  to 
have  the  child  properly  rubbed  until  the  skin  is  reddened 
with  a  Turkish  towel,  followed  by  massage  with  oil  or 
vaselin. 


CHAPTEE  XLIII. 

Statistics. 

The  recorded  births  of  tlie  three  years  1890,  1891, 
and  1892,  according  to  the  New  York  Board  of  Health, 
were  135,602. 

It  is  estimated  that  this  represents  only  five-sixths  of 
the  actual  number  born;  so  that  162,721  would  really 
represent  the  actual  number  of  births  for  this  period. 
During  the  same  time  the  number  of  deaths  of  children 
under  five  years  of  age  were  52,213,  representing  over 
32  per  cent,  of  the  whole  number  of  births. 

In  July,  1893,  the  deaths  of  children  under  five  years 
of  age  numbered  2796.  During  the  same  month  of  1894, 
2562.  In  August,  1893,  there  were  1686.  In  August, 
1894,  1559.  During  eight  months  ending  in  August  the 
deaths  under  five  years  of  age  were:  1895,  13,287;  1896, 
12,734;  1897,  10,962.  During  June,  July,  and  August 
of  1896  there  were  5671  deaths.  During  the  same  period 
of  1897,  5041.  In  1897  and  in  1902  we  had  a  cool  sum- 
mer. 

The  following  tables,  compiled  from  the  vital  statis- 
tics of  the  Board  of  Health,  show  the  relative  death-rate 
and  the  infant-population  in  (old)  New  York  City. 

Deaths  and  Death-eates  op  Children  under  Five  Years 

oe  Age,  for  the  Months  of  June, 

July,  and  August. 

Tear.  Population.  Deaths.  Death-rate. 

1891  188,703  5,945  126.0 

1892  194,214  6,612  136.1 

1893  199,886  5,892  117.9 

1894  205,723  5,788  112.5 

1895  212,983  6,183  116.1 

1896  216,728  5,671  104.7 

(286) 


STATISTICS.  287 

Year.  Population.  Deaths.  Death-rate. 

1897  220,641  5,041  91.4 

1898  224,736  5,047  89.8 

1899  229,029  4,689  81.9 

1900  ...;..   233,537  4,562  78.1 

1901    238,279  4,642  77.9 

1902    243,500  4,387  72.1 

Population,  Deaths,  and  Death-rates  of  Children  Under 
Five  Years  of  Age  from  1891  to  1902 
in  (old)  New  York  City. 

Year.           Population.  Deaths.  Death-rate. 

1891  188,703  18,224                      96.6 

1892  194,214  18,684                      96.2 

1893  199,886  17,865                      89.4 

1894  205,723  ■           17,558                      85.3 

1895  ......   212,983  18,221  85.6 

1896  216,728  16,807  77.5 

1897  220,641  15,395  69.8 

1898  224,736  15,591  69.3 

1899  229,029  14,391  62.8 

1900  233,537  15,648  67.0 

1901  238,279  14,809  62.1 

1902  243,500  15,019  61.7 

As  the  census  authorities  have  not  yet  supplied  the  figures  of 
the  number  of  children  living  under  five  in  our  city,  the  above 
population  represents  an  estimation  based  on  the  supposition  that 
the  same  proportion  of  children  under  five  to  total  population 
exists  to-day  as  existed  in  the  census  of  1895 :75  to  wit,  11.37  per 
cent. 

The  author  desires  to  thankfully  acknowledge  the 
kindness  of  Dr.  "William  H.  Guilfoy,  of  the  New  York 
Health  Department,  in  furnishing  the  above  statistics. 

75  According  to  the  census  of  June  1,  1900,  11.46  per  cent. 


CHAPTER  XLIV. 

Rachitis  (Rickets). 

Prof.  Paul  Zweifel,  in  his  recent  work  (1900)  on 
the  above  subject,  says:  "That  the  addition  of  water  to 
raw  milk  aids  in  the  digestion  of  the  same,  whereas  the 
addition  of  an  equal  quantity  of  water  to  boiled  milk 
produces  just  the  opposite  effect."  Thus  it  would  ap- 
pear, from  the  experiments  of  this  author,  that  raw  cows' 
milk  diluted  with  an  equal  quantity  or  even  more  water 
will  be  much  more  easily  assimilated  than  diluted  boiled 
milk. 

Zweifel  agrees  with  Schlesinger,  of  Breslau,  "that 
the  addition  of  water  to  milk  does  not  render  it  more 
digestible."  Clinical  investigations  by  such  authorities  as 
Professor  Baginsky,  in  Berlin,  have  proved  conclusively 
that  whole  milk  (undiluted)  cannot  be  fed  to  infants  with 
weak  digestive  powers  or  those  suffering  with  dyspepsia 
without  aggravating  the  dyspeptic  conditions  and  threat- 
ening the  very  existence  of  the  child.  Time  and  time 
again  has  the  author  tried  to  increase  the  weight  of  chil- 
dren and  to  strengthen  them  by  giving  them  more  con- 
centrated food.  These  experiments  would  have  proved 
disastrous  in  winter  but  for  the  rapid  withdrawal  and 
substitution  of  the  requisite  diluted  milk  solution  neces- 
sary for  the  age  of  the  infant. 

THE    ADDITION    OF    TABLE-SALT. 

The  addition  of  table-salt  has  given  such  satisfactory 
results  when  added  to  milk  that  Zweifel  insists  on  its  ad- 
vantage -in  preventing  rickets.  When  a  large-size  thimble 
is  tilled  with  salt  it  will  hold  about  3  grammes.  The 
smaller  thimbles  will  hold  about  2.5  grammes  of  salt.  If 
(288) 


RACHITIS.  289 

this  quantity  (3  grammes)  of  table-salt  is  added  to  1  pint 
of  water  (500  cubic  centimetres),  then  we  have  a  solu- 
tion approximating  the  decinormal  salt  solution  commonly 
known  as -the  physiological  normal  salt  solution.  Zweifel 
maintains  that  both  sterilizing  and  boiling  the  milk,  ac- 
cording to  the  Soxhlet  method,  does  not  render  it  more 
indigestible.  On  the  other  hand,  he  believes  that  the 
albuminoids  of  the  milk  are  rendered  more  difficult  to 
digest,  and  thus  he  believes  that  boiling  might  be  a  factor 
in  producing  rickets. 

Rickets  is  caused  by  the  substitutes  for  milk  rather 
than  by  milk  itself. 

When  children  are  improperly  fed  so  that  the  body 
is  underfed,  muscle-  and  bone-  formation  will  be  slow. 
Thus  it  is  that  the  eruption  of  the  teeth  will  be  delayed, 
and  this  is  one  of  the  most  prominent  symptoms  of  rick- 
ets. The  bones  show  the  most  characteristic  result  of 
improper  nutrition,  for  they  are  very  soft  and  spongy. 
They  will  yield  to  the  weight  of  the  body  if  used  in 
walking,  and  thus  it  is  that  bow-legs  with  extensive  curva- 
tures form  such  a  prominent  feature  in  showing  the  result 
of  using  soft  bones.  The  most  typical  symptoms  can  be 
studied  on  the  head  and  spine.  Thus,  craniotabes  can  be 
explained  by  a  deficient  nutrition  in  which  the  cranial 
bones  will  be  found  so  soft  that  they  will  yield  to  the 
pressure  of  the  thumb.  The  cranial  bones  will  frequently 
be  found  to  be  as  soft  and  as  thin  as  pasteboard.  The 
spine  is  most  frequently  deformed,  and  will  show  a  typical 
rachitic  kyphosis. 

CAUSES. 

The  majority  of  children  suffering  with  rickets  are 
or  were  bottle-fed  children.  Thus,  it  is  apparent  that  no 
food  can  equal  or  east-feeding,  he  it  mother  or  wet-nurse, 
in  preventing  rickets.  There  are  a  great  many  other 
causes,  such,  for  example,  as  bad  sanitary  measures  and 
faulty  hygiene.     Breast-fed  children  will  sometimes  show 


290  INFANT-FEEDING. 

rickets  when  they  have  been  living  in  bad  apartments, 
breathing  foul  air,  and  not  being  properly  cared  for.  One 
of  the  most  frequent  causes  of  rickets  is  "prolonged"  nurs- 
ing. In  the  section  on  "Breast-feeding"  I  have  already 
pointed  out  the  necessity  for  making  a  proper  chemical 
examination  of  the  breast-milk  if  the  infant  "shows  no 
increase  in  weight."  We  know  that,  toward  the  end  of 
lactation,  not  only  do  the  proteids  diminish,  but  get  to 
such  a  low  percentage  that,  unless  we  combine  hand- 
feeding  by  adding  the  raw  white  of  egg,  steak-juice,  and 
other  proteids,  like  the  cereals,  to  the  nursing,  the  child 
will  be  underfed.  This  underfeeding  is  certainly  a  con- 
tributing factor,  both  to  the  causation  and  leading  to  the 
development  of  rickets. 

Children  that  have  suffered  prolonged  diarrhoeas  or 
with  severe  diseases — like  dysentery,  typhoid,  bronchitis, 
and  pneumonias — are  prone  to  the  development  of  rickets. 
Children  of  syphilitic  parents  and  whose  parents  are  tu- 
berculous are  more  prone  to  the  development  of  this 
disease.  Von  Bitter,  quoted  by  Professor  Baginsky,  says 
that,  in  twenty-seven  cases  out  of  seventy-one  examined 
by  him,  rickets  was  not  only  found  in  the  children,  but 
as  well  in  the  mothers  of  these  same  cases.  Thus  it  is 
that  Kassowitz  and  Schwarz76  have  mentioned  the  exist- 
ence of  congenital  rickets.  This  same  author  found  that 
80  per  cent,  of  children  born  in  the  Vienna  Lying-in 
Hospital  were  rachitic.  This  statement  is  not  so  easily 
accepted,  however,  for  neither  Professor  Baginsky  nor 
Virchow  accept  the  same.  Experimentally,  it  has  been 
found  as  long  ago  as  1842  by  Chossat  that  when  lime 
is  deducted  from  the  nourishment  of  young  animals 
not  only  soft  bones  result,  but  they  finally  die.  Heitz- 
mann  maintains  that,  if  lactic  acid  is  introduced  into  the 
food  of  young  animals,  the  result  will  be,  first,  rickets, 
and,  later  on,  osteomalacia  will  result  therefrom.     Clin- 


'Wiener  medicinische  Jahrbucher,"  1887,  vol.  viii. 


RACHITIS.  291 

ical  investigations  have  shown  that  cases  of  rickets  occur 
more  often  during  the  winter  months;  thus  it  is  ap- 
parent that  improper  ventilation  is  one  of  the  most  ex- 
citing causes  of  this  disease. 

The  prognosis  of  infants  suffering  with  rickets  depends 
upon  the  amount  of  damage  already  done.  If  deformities 
of  the  spine,  of  the  head,  of  the  legs,  and  arms  exist, 
careful  orthopaedic  treatment  will  certainly  modify  the 
condition.  The  backbone  of  the  treatment  will,  how- 
ever, consist  in  studying  "the  dietetic  requirements  of 
the  case."  In  this  disease  more  than  in  any  other  will 
the  advantages  of  a  carefully  regulated  diet  be  apparent, 
if  the  hygienic  factors  and  proper  medicinal  treatment 
are  included. 

Rachitic  children  require  milk,  meat,  and  eggs ;  plenty 
of  cereals,  like  wheat,  barley,  rice,  farina,  sago,  oatmeal, 
hominy;  they  require  butter,  and,  if  they  will  not  take 
butter,  then  codliver-oil  or  lipanin;  iron  will  be  found 
valuable,  as  well  as  Fellows's  hypophosphites ;  malt-extract 
and  ferrum  lacticum  are  indicated.  Great  emphasis  must 
be  put  on  the  value  of  fresh  air  and  sunshine  in  the  treat- 
ment of  this  disease. 

EXTERNAL    TREATMENT. 

Bathing  in  sea-salt,  taking  1  to  2  pounds  of  salt  to  a 
bath-tub  of  water,  to  which  malt-extract,  about  1  teacup- 
ful,  is  added;  in  the  place  of  malt  Baginsky  advises  2 
ounces  of  calamus-root.  I  have  seen  very  good  results 
follow  the  continued  use  of  bran  and  sea-salt,  of  which 
2  to  3  pounds  of  bran  and  a  pound  of  sea-salt  are  placed 
in  a  bag  made  of  cheese-cloth.  This  bag  is  put  into  the 
bath-tub  one-half  hour  before  putting  the  baby  in  it. 
Enough  water  is  then  added  to  bathe  the  child ;  the  tem- 
perature of  the  bath  should  be  from  80°  to  100°  F.,  my 
preference  being  for  a  cool  bath,  really  tepid,  temperature 
of  90°  F. ;  duration  of  bath,  from  5  to  10  minutes,  fol- 
lowed by  a  good,  brisk  rub  with  a  coarse  Turkish  towel. 


292  INFANT-FEEDING. 

Massage  of  the  muscles  aided  by  passive  movements 
will  be  found  very  valuable  in  producing  a  better  mus- 
cular development,  aiding  metabolism,  and  stimulating 
the  circulation  in  general.  The  great  susceptibility  of 
rachitic  children  to  colds  and  coughs,  especially  to  croup, 
can  certainly  be  modified  if  such  children  will  be  given 
cold  baths,  cold  sponging,  cold  spray,  or  a  cold  douche. 
Such  children  should  not  be  overbundled  with  clothing, 
and  while  I  insist  on  protecting  the  lungs  and  the  whole 
body  from  sudden  changes  in  the  weather,  the  use  of  too 
much  clothing  will  certainly  tend  to  increase  the  amount 
of  perspiration,  and  thus  add  to,  rather  than  mitigate,  our 
trouble. 

INTERNAL    TREATMENT. 

Kassowitz  Formulae. — 

1.  F*  Phosphori  puri,  0.01. 

01.  amygdal.,  70.00. 
Sacch.  alb.,  30.00. 
JEiher.  fragar.,  gtt.  xx. 

2.  R  Phosphori  puri,  0.01. 

Solve  in  ol.  amygdal.  dulc,  10.00. 
Pulv.  gunimi  arab.,  5.00. 
Sirupi  simpl.,  5.00. 
Aq.  dest.,  80.00. 

3.  B  Phosphori  puri,  0.01. 

Ol.  amygdal.,  30.00. 
Pulv.  gumnii  arab.,  15.00. 
Sacch.  alb.,  15.00 
Aq.  dest.,  40.00. 

Of  the  above  mixtures,  1  to  2  teaspoonfuls  per  day; 
so  that  children  would  receive  x/2  milligramme  (0.0005) 
of  phosphorus,  and  in  prescribing  100  grammes  of  cod- 
liver-oil  or  in  the  emulsion  containing  the  above-men- 
tioned dose  of  phosphorus  the  quantity  would  last  twenty 
days.  Formula  'No.  1,  given  by  Professor  Kassowitz,  of 
Vienna,  does  not  mix  well;  neither  does  Formula  3;  so 
that  Formula  2  is  the  only  one  available  for  practical 


Fig.  53. — Athrepsia  Infantum. 


RACHITIS.  293 

purposes,  and  may  be  used.  A  chemical  test  for  the 
presence  of  phosphorus  will  always  yield  a  positive  result. 
Thus  far  the  specific  action  of  unoxidized  pure  phosphorus 
has  not  yet  been  proved.  In  fact,  such  keen  observers 
as  Baginsky  and  Henoch  do  not  believe  that  phosphorus 
in  its  pure  state  is  applicable. 

A  very  valuable  drug  in  the  treatment  of  rickets  is 
the  following:  Glycerophosphate  of  lime,  in  doses  of  1 
to  5  grains  for  an  infant  one  year  old,  to  be  given  im- 
mediately after  feeding.  For  a  child  six  months  old  one- 
half  the  dose. 

When  this  disease  is  associated  with  anaemia  or  very 
great  weakness  or  where  it  is  desirable  to  tone  up  the 
general  system,  then  add  to  the  glycerophosphate  of  lime 
an  equal  dose  of  the  glycerophosphate  of  iron.  This  drug 
treatment  should  be  continued  for  several  months  before 
expecting  results.  It  is  understood  that  the  author  insists 
on  a  radical  change  of  diet,  and  also  the  strictest  hygienic 
treatment,  when  possible.  All  factors  will  be  more  es- 
sential than  merely  giving  an  infant  a  few  doses  of  drugs. 


OHAPTEE  XLV. 

Scurvy  (Scorbutus). 

This  is  a  constitutional  disease  resulting  from  im- 
proper feeding.  It  usually  occurs  before  the  end  of  the 
second  year,  and  rarely  occurs  before  the  first  six  months 
of  a  child's  life.  As  in  adults,  scurvy  is  found  when  fresh 
food  has  been  withdrawn  from  the  dietary.  It  is  natural, 
therefore,  to  look  for  scorbutic  cases  among  children  who 
are : — 

First. — Deprived  of  breast-milk. 

Second. — In  those  brought  up  exclusively  on  milk 
which  is  devitalized  by  prolonged  sterilization. 

Third. — It  is  found  in  children  brought  up  on  con- 
densed milks  and  proprietary  foods  to  which  fresh  milk 
has  not  been  added.  There  seems  to  be,  therefore,  a 
direct  relationship  between  the  absence  of  fresh  milk,  be 
it  cows'  milk  or  human  milk,  and  the  development  of  this 
disease. 

Profound  ansemia  and  tendencies  to  haemorrhage  usu- 
ally are  the  most  prominent  symptoms.  The  most  im- 
portant symptoms  are,  according  to  Starr:  First,  immo- 
bility, progressing  to  pseudoparalysis;  intense  hyper- 
esthesia and  general  swelling,  situated  most  frequently 
in  the  legs,  but  not  limited  to  these  members;  the  in- 
vesting skin  is  shiny  and  tense,  but  there  is  neither 
oedema  nor  local  heat;  the  subsidence  of  the  general 
swelling  reveals  deep  fusiform  thickening  about  the  shafts 
of  the  long  bones,  in  the  neighborhood  of  the  joints.  In 
extreme  cases  there  is  a  tendency  to  fracture  near  the 
epiphysis.  Second,  the  gums  about  the  erupted  teeth  are 
swollen,  and  purple  in  color,  and  in  marked  cases  become 
spongy  and  readily  bleed.  Third,  the  rapid  disappearance 
(294) 


Fig.  54. — Athrepsia  Infantum. 


SCURVY.  295 

of  all  symptoms  upon  the  institution  of  a  proper  anti- 
scorbutic diet. 

This  disease  is  liable  to  occur  in  either  sex;  it  is  not 
influenced  by  climate  or  locality;  it  is  found  as  well  in 
the  best  as  in  the  poorest  hygienic  surroundings.  By  far 
the  greatest  number  of  cases  is  found  among  the  rich.  It 
is  evident  that  this  disease  is  due  to  improper  feeding 
more  than  to  an  improper  hygiene.  Some  authors  believe 
that  this  disease  is  caused  by  a  specific  micro-organism; 
this  latter  fact  has  not  yet  been  definitely  settled. 

It  is  interesting  to  note  the  various  views  expressed 
by  competent  observers  upon  this  subject;  thus,  while  a 
large  majority  of  clinicians  hold  that  sterilized  milk  per 
se  does  cause  scurvy,  Eotch  states  that  it  does  not,  in  his 
own  experience,  seem  to  do  so.  Starr  maintains  just  the 
reverse  of  Rotch,  and  believes  that  sterilized  milk  is  a 
causative  factor.  From  my  own  experience  I  quite  agree 
that  sterilized  milk — especially  the  prolonged  sterilization, 
by  which  the  albumins  are  changed,  and  by  which  this 
prolonged  heating  causes  devitalization,  which  is  so  inim- 
ical to  successful  feeding — is  a  causative  factor  in  this 
disease. 

It  is  peculiar  that  scurvy  will  be  cured  by  giving  raw 
milk,  fresh  fruits,  and  acid  fruits;  yet  still  we  find  that 
a  great  many  clinicians  persist  in  prescribing  sterilized 
milk  until  either  rickets  or  scurvy  is  established.  It  was 
for  this  reason  that  at  a  discussion  on  infant-feeding  at  the 
Academy  of  Medicine,  October  18,  1900, 1  was  led  to  in- 
sist on  the  use  of  raw  milk  as  the  proper  means  of  feeding 
children. 

Raw  milk  possesses  certain  advantages  over  boiled 
milk;  it  is  more  readily  assimilated  and  the  proteids  are 
not  so  difficult  to  digest.  It  is  a  well-known  fact  that 
boiled  milk  and  sterilized  milk  have  a  tendency  to  produce 
constipation,  whereas  the  opposite  is  true  of  raw  milk. 

Improper  infant-food  has  additional  disadvantages 
when  it  is  subjected  to  excessive  heating.    The  large  num- 


296  INFANT-FEEDING. 

ber  of  failures  with  milk  modified  at  a  laboratory  are  not 
so  much  dtie  to  the  process  involved  in  the  modification 
as  to  the  amount  of  heat  that  the  food  is  subjected  to 
prior  to  being  imbibed. 

Where  milk  is  modified  for  infant-feeding,  using  raw 
milk  only,  I  have  never  seen  constipation;  the  reverse, 
however,  has  always  been  true  when  milk  was  modified 
and  then  subjected  to  sterilization.  The  vital  point  has 
always  impressed  me  as  being,  not  so  much  to  sterilize 
milk  after  it  has  been  drawn  from  the  cow,  but  to  apply 
the  principle  of  sterilization  to  the  stable,  the  cow,  the 
utensils,  the  milker's  hands,  and  to  everything  coming  in 
contact  with  the  milk  from  the  time  it  leaves  the  cow's 
udder  until  it  is  fed  to  the  baby. 

When  oatmeal-gruel  or  barley-gruel  is  given  with  an  in- 
sufficient quantity  of  cows'  milk  and  then  fed  for  a  long  time, 
we  must  not  be  surprised  to  find  a  case  of  scurvy.  When  pro- 
prietary foods  are  given  without  the  addition  of  fresh  milk, 
then  scurvy  will  usually  result.  When  cream-mixtures  are 
given  which  are  deficient  in  fat  and  proteids,  then  scurvy  may 
result.  Thus  we  find  that  the  true,  underlying  cause  of  scurvy 
is  starvation  due  to  deficiency  of  one  or  more  nutritive  ele- 
ments in  the  food  given. 

The  following  case  of  scurvy  will  illustrate  the  con- 
dition : — 

A  child,  13  months  old,  was  brought  to  me  with  a  history  of 
being  very  restless  and  having  lost  considerable  Aveight.  The  child 
showed  a  shriveled  appearance  of  the  skin;  its  normal  elasticity 
Avas  gone;  the  skin  Avas  dry;  the  thorax  was  pigeon-breasted;  the 
arms  and  legs  Avere  thin;  both  arms  and  legs  showed  marked  ten- 
derness on  the  slightest  motion;  there  was  baldness  at  the  occiput, 
and  the  anterior  fontanelle  Avas  not  closed;  the  child  had  eight  teeth, 
all  of  which  were  slightly  carious;  the  gums  around  the  teeth  were 
deeply  congested  and  showed  bluish  ridges;  the  gums  were  spongy 
and  bled  very  easily;  there  was  an  intense  foetor  to  the  breath;  the 
child  had  been  suffering  from  diarrhoea  for  the  past  two  months, 
with  occasional  periods  of  constipation;  there  Avas  no  vomiting; 
the  appetite  had  always  been  very  poor.     The  previous  history  of 


scuevy.  297 

the  child  was  that,  when  born,  it  weighed  about  5  pounds ;  it  was 
very  small  at  birth.  The  mother  of  the  child  died  during  confine- 
ment, and  hence  the  baby  was  given  into  the  care  of  a  nursery. 
The  diet  consisted  of  1  teaspoonful  of  condensed  milk  with  12 
teaspoonfuls  of  water  and  a  small  pinch  of  sugar.  This  was  fed 
every  two  hours  for  a  period  of  over  two  months;  later  the  child 
was  put  on  barley-water,  to  which  some  condensed  milk  was  added. 
This  was  changed  from  time  to  time  to  a  diet  of  oatmeal-water 
and  condensed  milk. 

The  child  had  always  been  frail,  and  had  had  a  cough  and  also 
had  an  attack  of  acute  capillary  bronchitis;  during  the  summer 
the  child  had  a  severe  attack  of  cholera  infantum,  and  almost  lost 
its  life  from  vomiting  and  purging.  For  one  month  this  child  sub- 
sisted on  a  diet  of  oatmeal-water,  rice-water,  farina-water,  and 
albumin-water,  besides  cold  tea.  Thus  it  is  seen  that  the  child  re- 
ceived no  milk  for  a  period  of  over  seven  weeks.  When  the  child 
was  five  months  old  it  weighed  7  pounds,  and  at  this  time  it  hardly 
weighs  10  pounds.  There  is  a  marked  rachitic  kyphosis;  the  ribs 
are  beaded;  there  is  a  pendulous  belly;  the  child  has  an  umbilical 
hernia;  the  temperature,  taken  in  the  rectum  at  2  p.m.  for  a  period 
of  at  least  two  weeks,  was  no  higher  than  100°  to  101°  F.;  there  is 
an  intense  thirst;  the  kidneys  are  very  active;  the  urine  has  a 
very  high  color;  no  hematuria  could  be  found. 

The  diagnosis  of  infantile  scurvy  was  made  and  the  child  was 
put  on  the  following  treatment:  Orange-juice;  lemonade;  freshly- 
expressed  steak- juice;  raw  milk,  diluted  with  barley-water  or  rice- 
water,  equal  parts  (4  ounces  of  milk,  4  ounces  of  barley-water), 
repeated  every  three  or  four  hours,  depending  upon  the  appetite. 
Massage  of  the  body  was  very  gently  performed  with  codliver-oil 
or  vaselin,  to  lubricate  and  to  nourish.  A  1-drop  dose  of  nux 
vomica  was  ordered  before  each  feeding.  This  treatment  was  given 
continually  for  three  or  four  weeks.  Every  fourth  or  fifth  day  a 
half-ounce  of  barley-water  or  rice-water  was  withdrawn,  and  instead 
an  equal  quantity  of  fresh  milk  was  added;  hence,  after  four 
weeks  of  treatment  this  child  received  6  ounces  of  milk  with  2 
ounces  of  barley-water  or  rice-water  every  four  hours. 

The  child  was  sent  to  the  seashore,  and  after  this  treatment 
was  continued  for  seven  months  all  symptoms  of  scurvy  had  dis- 
appeared, though  the  symptoms  of  rickets  were  still  very  promi- 
nent. The  prognosis  now  is  very  good,  and  the  child  will  un- 
doubtedly recover. 

When  children  have  walked,  and  suddenly  stop  walk- 
ing and  will  not  creep,  then  attention  should  be  directed 


298  INFANT-FEEDTNG. 

to  the  state  of  the  gums  and  to  the  general  physical  con- 
dition. Such  cases  are  usually  suspicious,  and  show  the 
beginning  of  the  development  of  scurvy.  Indeed,  such 
symptoms  will  develop  long  before  there  is  a  general 
breaking-down.  Emaciation  and  anorexia  follow,  which 
are  associated  in  this  condition. 


CHAPTER  XLVI. 

Dentition  (Teething). 

The  teeth  usually  appear,  according  to  Professor 
Baginsky,  between  the  third  and  tenth  months,  though, 
as  a  rule,  between  the  ninth  and  tenth  months.  The 
usual  rule  is  for  normal  dentition  to  begin  about  the  sev- 
enth or  the  eighth  month. 

In  a  great  variety  of  children  premature  teething  is 
recorded;  I  have  seen  a  great  many  children  born  with 
two  and  more  teeth. 

Rachitic  children,  as  a  rule,  teeth  very  early  or  very 
late.  In  the  large  children's  service  with  which  I  have 
been  connected  I  have  observed  the  eruption  of  teeth 
many  times  as  early  as  two  or  three  months  in  very 
rickety,  bottle-fed  children.  These  teeth  soon  decay,  and 
are  then  known  as  carious  teeth. 

In  syphilitic  (congenital)  children  premature  denti- 
tion is  frequently  seen. 

The  first  teeth  are  known  as  milk-teeth. 

The  following  table  will  show  the  usual  rule  followed 
by  normal  dentition  in  the  average  child: — 

19  |  11  |  13  |  5  |  3  |  4  |  6  |  14  |     9  |  17 

20  |  12  |  15  |  7  |  T  |  2  |  8  |  16~|~T0~  |~18 

The  milk-teeth  are  twenty  in  number;  thus,  1  and  2 
are  the  lower  incisors,  usually  first  teeth;  then  follow  3 
and  4,  upper  incisors. 

Normal  children  usually  teeth  in  pairs,  and  not  singly, 
whereas  rachitic  children  usually  have  an  eruption  of 

(299) 


300 


INFANT-FEEDING. 


single  teeth,  and  distinct  backwardness  in  their  appear- 
ance. Deciduous  teeth,  commonly  called  milk-teeth,  re- 
main until  a  child  is  six  years  old,  when  the  permanent 
teeth  appear. 

Baginsky  emphasizes  the  fact  that  enough  stress  is  not 
laid  on  the  clinical  importance  of  carious  teeth  as  indi- 
cating tuberculosis  and  scrofulous  conditions.  In  the  sec- 
tion on  treatment  of  rickets  I  have  mentioned  the  value  of 
a  nitrogenous  diet,  especially  proteids  (albuminoids),  to 
aid  in  the  formation  of  bony  structures.  The  teeth  are 
also  included  in  this  category. 


Fig.  48. — Two  Middle  Lower  Incisors.    Three  to  10 
Months;  Average,  7  Months." 


Thus,  when  such  drugs  as  glycerophosphate  of  lime 
or  iron  and  hygienic  measures  are  indicated  for  the  treat- 
ment of  rickets  they  are  of  especial  value  where  back- 
wardness in  teething  exists. 


77 1  am  indebted  to  Dr.  Dillon  Brown  for  the  illustrations,  which 
have  recently  appeared  in  "The  Nursery." 


DENTITION. 


301 


Fig.  49. — Nine  to  16  Months.    Four  Upper  Incisors. 


Fig.  50. — Two  Lateral  Lower  Incisors  and  4  Anterior 
Molars.     Thirteen  to  17  Months. 


302 


INFANT-FEEDING. 


Fig.  51. — Four  Canines.     Sixteen  to  21  Months. 


Fig.  52. — Twenty-three  to  36  Months,  although  the  Average  is 
24  to  30  Months. 


CHAPTEK  XLYII. 

Athrepsia  Infantum.     (Marasmus,  ok  Atrophy;  Wast- 
ing Disease,  from  Malassimilation  of  Food.)78 

If  infants,  when  a  few  months  old,  suffer  with  vomit- 
ing or  diarrhoea,  and  this  condition  is  allowed  to  become 
chronic,  then  colic  and  flatulence,  associated  with  con- 
stipation, supervene,  and  result  in  a  gastro-intestinal  ca- 
tarrh. Neglect  of  this  condition  means  the  development 
of  the  condition  known  as  athrepsia.  The  infant  does  not 
thrive,  commences  to  waste,  and,  unless  we  realize  the 
condition  and  give  the  baby  proper  treatment,  such  a 
child  will  die  of  exhaustion  from  inanition.  When  these 
cases  linger  for  months,  they  develop  rachitis.  Recovery 
without  treatment  is  impossible.  Parrott  was  the  first  to 
define  this  disease,  and  classified  it  into  three  stages: — 

1.  The  infant  suffers  from  a  simple  diarrhoea  or  loose- 
ness of  the  bowels.  The  stools,  instead  of  being  bright 
yellow  and  homogeneous,  are  liquid,  curdy,  often  of  a 
green  color,  and  contain  an  excessive  quantity  of  mucus. 
The  abdomen  is  distended  with  gas  and  remains  con- 
stantly in  this  condition;  the  tongue  is  coated  and  the 
patches  of  a  stomatitis  appear  in  the  mouth.  The  infant 
is  restless,  constantly  whining,  and  will  not  sleep  at  night. 
The  milk,  being  retained,  curdles;  the  tissues  become 
flabby,  and  wasting  commences. 

2.  The  symptoms  are  intensified  and  the  character- 
istic wasting  becomes  manifest.  The  stools,  for  the  most 
part,  are  loose  and  frequent,  and  consist  of  undigested 
food;    they  are  often  pale  and  putty-like,  with  a  pecul- 

78  Presented  to  the  Section  on  Diseases  of  Children,  at  the 
Fifty-first  Annual  Meeting  of  the  American  Medical  Association, 
held  at  Atlantic  City,  N.  J.,  June  5-8,  1900. 

(303) 


304  INFANT-FEEDING. 

iar  odor.  At  other  times  they  are  dark  brown,  from  the 
presence  of  altered  bile.  The  infant  is  most  voracious, 
liquid  food  does  not  seem  to  satisfy  it,  and  by  the  mis- 
taken kindness  of  its  friends  it  is  fed  with  some  thick 
food,  like  soft  bread,  a  diet  which  has  the  great  advantage, 
in  their  eyes,  of  keeping  it  quiet  for  a  longer  time  than 
liquid  food  or  diluted  milk.  At  times  it  can  hardly  be 
made  to  sleep,  or  only  dozes  for  a  short  time,  unless  under 
the  influence  of  a  soothing-syrup  applied  by  its  nurse. 
The  mouth  becomes  the  seat  of  a  parasitic  stomatitis; 
the  skin  is  harsh  and  dry;  small  boils  or  a  lichenous  rash 
make  their  appearance.  The  buttocks  and  genitals  are 
raw  and  excoriated.  The  temperature  is  below  normal; 
the  feet  and  hands  are  congested;  the  face  has  a  pallid, 
earthy  tint;  and  a  sickly  lactic-acid  smell  is  given  out 
from  the  body,  especially  the  abdomen.  The  wasting  is 
extreme,  the  face  being  shriveled,  the  skin  wrinkled  and 
hanging  in  folds  about  the  thighs  and  arms. 

3.  The  third  stage  brings  the  child  into  a  moribund 
state.  It  is  too  feeble  to  cry,  becomes  heavy  and  drowsy, 
taking  little  notice  of  anything.  Death  then  ensues,  prob- 
ably preceded  by  a  muscular  twitching,  strabismus,  or  gen- 
eral convulsions. 

Henoch  does  not  like  the  term  "athrepsia,"  intro- 
duced by  Parrott,  but  prefers  "atrophy."  The  first  symp- 
tom that  this  author  noticed  is  that  the.  child's  weight 
does  not  increase;  and  hence  he  emphasizes  the  impor- 
tance of  frequently  weighing  children.  He  regards  the 
weight  taken  once  a  week  as  sufficient,  so  that  it  can  be 
a  determining  factor  as  to  the  progress  made  by  an  infant. 
Henoch  says  that  at  the  end  of  the  first  month  the  weight 
is  increased  one-third,  at  the  end  of  the  fifth  month  it  is 
double,  and  at  the  end  of  the  twelfth  month  it  should  be 
three  times  the  weight  at  birth.  Weaning,  dentition,  and 
all  other  pathological  conditions  interfere  with  a  proper 
increase  in  weight. 

By  far  the  greatest  number  of  cases  of  athrepsia  are 


ATI1REPSIA   INFANTUM.  305 

found  in  bottle-fed  children.  There  are,  however,  a  great 
many  cases  to  be  seen  among  breast-fed  children.  We 
can  then  be  positive  that  the  breast-milk  is  lacking  in 
some  of  its  chemical  constituents,  and  frequently  we  find 
that  it  is  the  proteids  that  are  deficient  in  quantity.  If, 
therefore,  we  meet  with  a  case  of  athrepsia  in  a  breast-fed 
child,  the  thing  to  do  is  to  have  a  chemical  examination 
made  of  the  breast-milk.  If  the  latter  is  found  deficient 
in  quality,  then  we  must  withdraw  it. 

A  great  many  children  will  be  found  to  thrive  at  once 
after  having  been  removed  from  the  breasts  and  changed 
to  some  artificial  mode  of  feeding,  whereas  the  reverse  is 
also  true.  If,  therefore,  we  wish  to  do  away  with  its  own 
mother's  milk,  for  some  positive  reason,  it  is  advisable  to 
secure  a  wet-nurse  having  a  child  as  near  as  possible  the 
age  of  the  one  she  is  to  suckle.  The  hereditary  history 
of  a  nurse  is  of  great  importance,  as  is  also  the  quantity 
and  quality  of  her  milk,  which  should  be  thoroughly  ex- 
amined before  she  is  given  this  foster-child. 

The  treatment  of  this  disease  is  one  which  resolves 
itself  into  removing  the  cause,  and  if  bad  hygienic  sur- 
roundings— as  impure  air,  crowded  apartments,  and  im- 
proper diet — are  the  cause,  then  these  must  be  remedied 
at  once.  Medication  amounts  to  nothing  in  the  treatment 
of  this  disease. 

With  hand-fed  or  bottle-fed  children  we  can  easily 
regulate  the  condition  of  their  bowels,  and  also  easily 
regulate  the  quality  and  quantity  of  the  food  given 
them.  The  blandest  and  least  irritating  food  must  be 
selected,  while  frequent  weighing  of  the  infants  should 
be  resorted  to  in  order  to  ascertain  the  progress  that  is 
being  made. 

Where  there  is  much  diarrhoea,  milk  must  be  used 
sparingly  or  altogether  omitted  for  awhile,  as  the  hard 
curds  formed  in  the  stomach  are  beyond  the  weak  di- 
gestive powers  of  the  weakened  stomach  and  intestines. 
Small  quantities  of  whey  and  barley-water,  white  of  egg 


306  INFANT-FEEDING. 

and  barley-water,  or  the  juice  of  a  rare  chop  or  steak  may 
be  given  at  short  intervals  during  the  day  and  night. 

As  soon  as  the  child  improves  in  respect  to  the  diar- 
rhoea, milk  in  some  form  may  be  allowed.  Peptonized 
milk  is  often  of  much  value  in  these  diseases  when  made 
by  mixing  3  ounces  of  cold  milk,  adding  2  teaspoonfuls 
of  cream,  with  1/2  of  a  peptonizing  powder,  and  given 
to  the  infant  after  it  has  stood  for  fifteen  minutes. 

The  cream-mixtures  are  often  of  much  service,  such 
as  1  ounce  of  cream,  3  ounces  of  barley-water,  and  1  tea- 
spoonful  of  sugar.  Every  care  must  be  taken  that  the 
feeding-bottle  is  clean,  and  that  the  food  is  prepared  with 
the  most  scrupulous  neatness. 

The  great  difference  between  cows'  milk  and  human 
milk  is  the  fact  that  human  milk  is  persistently  alkaline, 
whereas  cows'  milk  is  usually  acid;  that  there  is  more 
nitrogenous  material  in  cows'  milk;  that  there  is  a  much 
smaller  percentage  of  milk-sugar  in  cows'  milk,  and, 
finally,  that  the  nitrogenous  constituents  of  the  milk  of 
the  cow  are  affected  by  rennet  in  a  manner  different  from 
those  of  mothers'  milk. 

In  order,  therefore,  to  feed  cows'  milk  to  infants, 
these  differences  must  be  corrected,  and  the  correction 
of  them  causes  further  differences,  which  have,  in  turn, 
also  to  be  corrected;  the  process,  therefore,  is  a  compli- 
cated one. 

Before  considering  the  means  adopted  to  alter  the 
chemical  composition  of  cows'  milk,  it  would  be  proper 
to  state  that  there  is  a  common,  but  false,  belief  that 
milk  from  one  cow  is  the  best  for  infants'  use.  The 
principle  that  underlies  this  belief  is  perfectly  right.  It 
is,  that  it  is  desirable  to  obtain  milk  of  uniform  compo- 
sition; but  it  has  been  found  experimentally  that  milk 
of  the  same  cow  varies  in  its  composition  during  twenty- 
four  hours,  and  that  it  is,  in  reality,  more  likely  that  a 
mixture  of  the  milk  from  several  cows  will  show  a  more 
constant  analytical  result  than  that  from  one  single  ani- 


ATHREPSIA   INFANTUM.  307 

mal.  Jacobi  and  others  have  stated  that  the  chances  of 
infection  from  tuberculosis  through  the  medium  of  milk 
can  only  be  lessened  by  feeding  from  a  large  number  of 
cows. 

In  order  to  render  the  character  of  cows'  milk  similar 
to  that  of  human  milk,  it  is  necessary  to  reduce  the  amount 
of  casein  in  cows'  milk.  This  is  usually  done  by  treating 
the  milk  with  water,  thus  diluting  it;  but  sometimes  lime- 
water  is  used,  for  the  reason  to  be  stated  immediately. 

Second,  the  proportion  of  fat  in  cows'  milk  is  less 
than  in  human  milk,  and  it  has  been  still  further  reduced 
by  dilution.  Therefore,  it  is  necessary  to  add  to  it  fat  in 
some  form  or  other,  and  this  is  commonly  done  by  adding 
cream. 

Thirdly,  sugar  must  be  added  to  cows'  milk  in  order 
to  bring  the  lactose  up  to  the  proper  level.  It  has  been 
held  by  some  that  it  is  necessary  to  use  milk-sugar  for 
this  purpose,  but  there  seems  to  be  little  doubt  that  cane- 
sugar  will  serve  the  purpose  quite  as  well,  or  even  better. 

In  the  fourth  place,  according  to  Jacobi,  it  is  neces- 
sary to  prevent  as  far  as  possible  the  great  coagulating 
effect  that  the  ferment  of  the  infants'  gastric  juice  has 
on  the  casein  of  cows'  milk,  and  this  is  satisfactorily  ac- 
complished by  adding  an  alkali,  such  as  lime-water,  or 
some  mucilaginous  material,  such  as  barley-water.  In 
this  way  the  casein  curd  is  rendered  loose  and  flocculent 
and  more  like  that  of  human  milk. 

Dr.  Meigs,  of  Philadelphia,  advises  the  preparation 
of  the  following  mixture:  Cream,  2  ounces;  milk  1 
ounce;  lime-water,  2  ounces;  sugar- water,  3  ounces;  the 
latter  is  made  by  dissolving  about  2  1/4  ounces  of  milk- 
sugar  in  a  pint  of  water. 

Condensed  cows'  milk  is  simply  cows'  milk  that  has 
been  evaporated  to  one-fourth  of  its  volume  and  sterilized, 
nothing  at  all  being  added  to  it.  Then,  again,  there  is  a 
form  in  which  the  milk  is  not  only  condensed,  but  has 
also  the  addition  made  to  it  of  about  50  per  cent,  of  cane- 


308  INFANT-FEEDING. 

sugar.  When  it  is  also  borne  in  mind  that  the  composi- 
tion of  condensed  milk  varies  with  the  season  of  the  year, 
great  fluctuations  must  occur  in  its  chemical  constitution. 

Condensed  milk  must  also  be  diluted  with  water  be- 
fore it  is  fit  for  use,  and  this  dilution  may  entirely  dis- 
arrange the  proportion  of  the  component  parts  of  the 
fluid.  For  this  reason  it  is  found  that  even  where  infants 
appear  to  thrive  on  condensed  milk,  their  apparent  good 
health  is  due  to  an  excessive  deposit  of  fat,  and  not  to  a 
sufficient  supply  of  albuminoids;  and  they  are,  in  the 
long  run,  more  prone  to  disease  than  babies  fed  on  the 
breast  or  on  cows'  milk  properly  prepared. 

The  above  remarks  apply  with  less  force  to  that  va- 
riety of  condensed  milk  which  is  made  from  sterilized 
fluid  and  then  sweetened;  but  even  this  preparation  re- 
quires for  digestibility  to  be  diluted  some  ten  times,  and 
this  reduces  its  nutritive  value  to  a  dangerous  degree. 

At  times  we  must  resort  to  various  methods  of  feed- 
ing, until  we  find  the  method  on  which  a  baby  will  thrive, 
and  so  it  is  that  we  have:  (1)  humanized  milk,  (2)  steril- 
ized milk,  (3)  pasteurized  milk,  and  (4)  peptonized  milk. 

1.  Humanized  milk  is  simply  cows'  milk  diluted  with 
a  certain  amount  of  whey  and  with  some  cream.  It  is 
prepared  in  the  following  way:  A  pint  of  milk  is  set 
aside  in  a  cool  place  until  the  cream  rises  to  the  surface. 
This  is  skimmed  off  and  kept,  and  to  the  milk  remaining 
is  added  enough  rennet  to  curdle  it  thoroughly.  The 
whey  is  strained  off  from  the  curd  and  added  with  the 
cream,  previously  separated,  to  a  pint  of  fresh  cows'  milk, 
and  the  mixture  is  known  as  humanized  milk.  It  is  dis- 
tinctly more  digestible  than  ordinary  diluted  milk,  and 
often  agrees  well  with  young  infants,  being  given  with- 
out any  further  dilution,  in  quantities  suitable  to  the  age 
of  the  infant.  It  may  be  employed  exclusively  during 
the  first  three  months  of  the  infant's  life,  and  after  that 
age  may  be  used  in  combination  with  some  farinaceous 
food. 


ATHREPSIA   INFANTUM.  309 

2.  Sterilized  milk  is  that  in  which  all  germs  tending 
to  decompose  it  have  been  destroyed  by  exposure  to  a 
boiling  heat  at  a  temperature  of  212°  F.  for  a  short 
period  of  time:  from  15  to  45  minutes.  Fresh  cows' 
milk  always  contains  impurities  received  from  the  cow 
or  the  atmosphere  or  from  the  vessels  in  which  it  is  con- 
tained, though  much  care  may  have  been  taken  to  main- 
tain absolute  cleanliness.  The  milk  is  usually  exposed 
to  the  action  of  steam  or  in  a  boiling  heat  from  15  to  45 
minutes,  and  will  keep  about  24  hours.  A  fresh  bottle 
must  always  be  opened  for  each  meal;  if  anything  is  left 
in  the  bottle  after  the  baby  has  finished,  it  must  be  thrown 
out. 

3.  Pasteurized  milk  is  simply  steamed  at  a  tempera- 
ture of  140°  to  170°  F.,  for  about  30  minutes;  in  other 
Avords,  it  is  really  sterilized  milk  at  a  lower  temperature. 

4.  Peptonized  milk,  the  fourth  substitute  for  ordi- 
nary diluted  milk,  is  as  simple  a  preparation  as  sterilized 
milk.  It  consists  of  milk  which  has  previously  been  par- 
tially digested  by  the  addition  of  some  preparation  of  a 
digestive  ferment,  among  the  best  known  of  which  are 
Benger's  liquor  pancreaticus,  Fairchild's  peptonizing  pow- 
ders, etc.  The  milk  should  be  diluted  to  some  extent 
before  being  peptonized;  but  it  is  not  necessary  to  dilute 
to  such  an  extent  as  has  been  recommended  for  ordinary 
cows'  milk.  Generally,  even  for  an  infant  two  or  three 
days  old,  the  addition  of  an  even  quantity  of  barley-water 
will  be  sufficient,  and,  when  a  baby  is  two  or  three  months 
old,  a  dilution  of  2  parts  of  milk  with  1  part  of  water  will 
be  digested  with  comfort. 

In  France  there  is  a  law  forbidding  anyone  to  give 
solid  food  of  any  kind  to  infants  under  a  year  without 
the  written  authority  of  a  qualified  medical  man. 

Jacobi  says:  "Whatever  I  have  here  brought  forward 
is  certainly  not  to  disparage  the  boiling  of  the  milk;  it 
is  to  prove  the  danger  of  relying  on  a  single  preventive 
when  the  causes  of  intestinal  disorders  are  so  many."     It 


310  INFANT-FEEDING. 

is  true,  however,  that  the  large  majority  of  the  latter  de- 
pends on  causes  which  may  be  met  by  sterilization,  but 
not  by  sterilization  only;  also  by  pasteurization,  that  is, 
heating  the  milk  to  70°  C.  (165°  F.),  and  keeping  it  at 
that  uniform  temperature  for  30  minutes:  a  procedure 
which  destroys  the  same  germs  that  are  killed  by  a  more 
elevated  temperature,  without  much  change  in  flavor  and 
taste. 

One  of  the  questions  connected  with  the  employment 
of  sterilized  or  pasteurized  milk  is  this:  whether  the  milk 
to  be  used  for  a  child  ought  to  be  prepared  at  home,  or 
whether  the  supply  may  be  procured  from  an  establish- 
ment where  large  quantities  of  milk  believed  to  become 
immutable  by  sterilization  for  an  indefinite  period  are  kept 
for  sale.  In  regard  to  this  problem  Fliigge  plainly  ex- 
presses his  regrets  that  "we  have  allowed  ourselves  to  be 
guided  by  people  who  are  neither  hygienists  nor  physi- 
cians, but  chemists,  farmers,  or  apothecaries,  and  whose 
actions  have  been  based  on  three  false  beliefs.  Of  these 
the  first  is  that  boiling  for  three-quarters  of  an  hour  de- 
stroys germs;  the  second  that  whatever  bacteria  remain 
undestroyed  are  innocuous,  and  the  third,  that  proliferat- 
ing bacteria  can  always  be  recognized  by  symptoms  of 
decomposition."  Nothing  is  more  erroneous.  Soxhlet 
himself,  the  German  originator  of  sterilization,  knew  at 
an  early  time  that  the  fermenting  process  is  now  and  then 
but  partially  interrupted  by  boiling,  that  butyric  acid  may 
be  found  in  place  of  lactic  acid,  that  a  strong  evolution 
of  gas  may  be  caused  after  much  boiling,  and  that  such 
milk  may  give  rise  to  flatulency.  Aye,  milk  which  hap- 
pens to  contain  the  resistant  spores  of  bacteria  becomes 
a  better  breeding-ground  for  them  by  the  very  elimina- 
tion of  lactic  acid,  and  the  longer  such  sterilized  milk  is 
preserved  and  offered  for  sale,  the  worse  is  its  condition. 
It  may  be  true  that  these  conditions  are  not  met  with  very 
frequently,  but  an  occasional  single  death  in  a  family 
caused   by   poisonous   milk   will   be   more   than    enough. 


ATHREPSIA   INFANTUM.  311 

Therefore,  the  daily  home-sterilization  is  by  far  preferable 
to  the  risky  purchase  from  wholesale  manufacturers  who 
cannot  guarantee,  because,  in  the  nature  of  things,  they 
cannot  know,  the  condition  of  their  wares. 

Another  alteration  of  a  less  dangerous  character,  but 
far  from  being  desirable,  is  the  separation  of  cream  from 
sterilized  milk  which  is  preserved  for  sale.  Renk79  found 
it  to  take  place  to  a  slight  extent  during  the  very  first 
weeks,  but  later  to  such  a  degree  that  43.5  per  cent,  of 
all  the  cream  contained  in  the  milk  was  eliminated. 

Sterilization  has  been  claimed  to  be  no  unmixed  boon, 
because  of  its  changing  the  chemical  constitution  of  milk. 
Still,  the  opinions  on  that  subject  vary  to  a  great  extent, 
the  occurrence  of  changes  being  both  asserted  and  denied 
by  apparently  competent  judges.  But  what  I  have  said 
a  hundred  times  is  still  true  and  borne  out  by  facts,  viz. : 
that  no  matter  how  beneficial  boiling,  or  sterilization,  or 
pasteurization  may  be,  they  cannot  transform  cows'  milk 
into  woman's  milk,  and  that  it  is  a  mistake  to  believe  that 
the  former,  by  mere  sterilization,  is  a  full  substitute  for 
the  latter.  It  is  true  that  when  we  cannot  have  woman's 
milk  we  cannot  do  without  cows'  milk.  There  is  no 
alleged  substitute  that  can  be  had  with  equal  facility  or 
in  sufficient  quantity.  But  after  all  it  is  not  woman's 
milk.  Babies  may  not  succumb  from  using  it,  and  may 
seldom  appear  to  suffer  from  it;  indeed,  they  will  mostly 
appear  to  thrive  on  it,  but  it  is  a  make-shift  after  all,  and 
requires  modifications.  Hammarsten  was  the  first  to  prove 
the  chemical  difference  between  the  casein  of  cows'  milk 
and  of  woman's  milk.  Whatever  was  known  on  that  sub- 
ject at  that  time  I  collated  in  Gerhardt's  "Handbuch  der 
Kinderk.,"  vol.  i,  1875  (second  edition,  1882).  But  lately 
Wroblewski  demonstrated  the  difference  in  solubility  of 
the  two  milks.  Woman's  casein  retains,  during  pepsin  di- 
gestion, its  nuclein — proteid  rich  in  phosphorus — in  solu- 


1  Archiv  fur  Hygiene,  xvii. 


312  INFANT-FEEDING. 

tion,  wliicli  is  fully  digested;  in  cows'  casein  the  nuclein 
is  not  fully  digested, — a  "paranuclein"  is  deposited  un- 
dissolved and  undigested. 

Henry  A.  Bunker,  in  an  article  on  the  modification 
of  cows'  milk,  says  that  the  difficulty  of  the  digestion  of 
the  casein  of  cows'  milk  in  some  children  has  seemed  to 
be  the  resistance  to  the  infant's  digestive  powers,  even 
after  the  partial  hydration  supposed  to  be  brought  about 
by  hydrochloric  acid  and  heat.  In  all  such  cases  the  faecal 
evacuations  were  white,  hard,  and  dry,  such  as  occur  so 
often  on  a  plain,  sterilize.d-milk  diet.  In  many  of  these 
cases,  these  dry,  scybalous  masses  would  frequently  set 
up  mucous  diarrhoea  and  give  rise  to  severe  colicky  pains. 

The  only  evidence  of  partial  hydration  by  the  acid 
and  heat  would  seem  to  be  the  fact  of  increased  nutri- 
tion in  spite  of  these  difficulties.  Professor  Chittenden80 
maintains,  and  proves  by  a  beautiful  laboratory  experi- 
ment, that  the  products  of  gastric  digestion  have  the  power 
of  combining  with  more  hydrochloric  acid  than  the  orig- 
inal proteid,  for,  as  soon  as  proteolysis  commences,  the 
products  so  formed  begin  to  show  their  greater  affinity  for 
acid  by  withdrawing  acid  from  its  combination  with  the 
native  proteid :  a  supposition  which  is  necessary  to  account 
for  even  the  starting  of  the  proteolytic  process.  Further, 
it  is  evident  that  proteoses  and  peptones  combine  with 
a  far  larger  equivalent  of  acid  than  the  native  proteid- 
albumin,  in  the  experiment.  This,  doubtless,  depends 
upon  the  cleavage  of  the  large  proteid  molecule  into  a 
number  of  smaller  or  simpler  molecules,  each  of  the  latter, 
perhaps,  combining  with  a  like  number  of  hydrochloric- 
acid  molecules.  However  this  may  be,  it  is  evident  that 
the  products  of  pepsin-proteolysis  combine  with  a  larger 
amount  of  hydrochloric  acid  than  the  mother-proteid,  and 
that  the  transformation  of  the  latter,  at  least  under  the 
conditions  of  the  experiment,  is  a  slow  and  gradual  process. 


"Cartwright  Lectures  on  Digestive  Proteolysis,"  1894. 


ATHREPSIA   INFANTUM.  313 

It  will  be  remembered  that  the  original  method  pro- 
posed the  hydration  of  the  milk-proteids  by  hydrochloric 
acid  and  a  rather  prolonged  boiling.  Twenty  drops  of  a 
10-per-cent.  hydrochloric-acid  solution  were  added  to  1 
pint  of  water  and  1  quart  of  milk,  and  this  mixture  was 
to  be  kept  at  boiling  temperature  for  about  twenty  min- 
utes. The  addition  of  a  larger  amount  of  the  acid,  unless 
the  milk  was  quite  fresh,  was  found  to  result  quite  fre- 
quently in  curdling  the  milk.  It  was  also  found  that  the 
acid  so  added,  up  to  the  point  of  saturation  or  breaking, 
exists  as  combined  acid,  as  was  evident  from  the  failure  of 
reagents  to  show  free  hydrochloric  acid  in  the  completed 
mixture. 

The  indications  that  the  hydration  secured  by  this 
method  is  not  always  sufficient  to  meet  the  requirements 
of  certain  infantile  stomachs,  and  the  fact  that  usually  in 
such  cases  the  nutrition  is  increased  in  spite  of  incomplete 
and  painful  digestion,  seemed  so  strongly  confirmatory  of 
the  results  of  Professor  Chittenden's  researches,  that  I 
determined  to  copy,  in  part,  his  experiments  on  HC1 
saturation,  as  applied  to  the  proteids  of  milk. 

To  this  end,  milk  was  prepared  in  the  original  way, 
except  that  the  20  drops  of  dilute  hydrochloric  acid  were 
added  in  1/2,  instead  of  1,  pint,  watery  solution,  and 
slowly,  but  intimately,  mixed  with  1  quart  of  milk.  This 
mixture  was  brought  as  rapidly  as  possible  to  the  boiling 
temperature  and  then  set  aside  until  another  half-pint  of 
water  was  prepared  with  20  drops  more  of  the  acid.  This 
was  added  to  the  previously  boiled  milk  and  acid,  stirred 
thoroughly,  and  again  brought  to  the  boiling-point.  The 
result  thus  obtained  was  a  thoroughly  palatable  milk,  with 
no  taste  of  having  been  boiled,  and  gave  no  indication  of 
free  hydrochloric  acid  with  Gunzberg's  reagent.  Ru- 
disch's  plan  is  similar  to  the  latter. 

Proteids  in  excess  are  indicated  by  the  presence  of 
curds  in  the  stools.  This  is  the  most  frequent  cause  of 
colic  in  infants.    Sometimes  there  is  diarrhoea,  more  often 


314  INFANT-FEEDING. 

constipation  when  "the  proteids  are  in  excess.  The  excess 
of  proteids  frequently  causes  vomiting  and  so  does  an 
excess  of  either  fat  or  sugar.  If,  therefore,  after  reducing 
the  percentage  of  proteids,  fat,  or  sugar,  vomiting  still 
persists,  then  we  must  feed  the  baby  with  smaller  quan- 
tities. Thus,  we  may  have  to  give  a  4-ounce  bottle  where 
a  6-ounce  or  a  5-ounce  feeding  causes  vomiting.  Certain 
rules  can  be  laid  down:  if  an  infant  does  not  thrive, — 
that  is,  does  not  gain  in  weight  without  showing  any  signs 
of  indigestion, — then  the  proportions — i.e.,  percentages  of 
all  ingredients — should  be  gradually  increased;  chiefly 
the  proteids,  however,  for  the  latter  is  the  most  important 
element  in  an  infant's  food. 

An  infant  soon  after  birth  was  put  on  modified  milk, 
containing : — 

Fat    2.00 

Milk-sugar    5.00 

Albuminoids   0.75 

Lime-water   Via 

I  ordered  eight  feedings,  2  ounces  in  each.  As  the 
child  was  constipated,  we  soon  after  increased  the  formula 
to  the  following  percentages: — 

Fat    2.50 

Milk-sugar    6.00 

Albuminoids   1.00 

Lime-water   Vie 

As  the  stools  did  not  change,  the  fat  was  increased 
to  3  per  cent.,  other  ingredients  the  same.  The  child 
gained  but  3  ounces  in  weight  in  five  weeks;  had  green- 
ish, curded  stools,  and  had  distinct  evidence  of  intestinal 
indigestion.  It  also  vomited  curds.  The  general  condi- 
tion of  the  child  was  one  of  extreme  irritability,  with  very 
little  sleep.  Hand-feeding  was  stopped.  The  child's  ali- 
mentary tract  was  thoroughly  cleaned,  and  a  wet-nurse 
secured.     This  happened  when  the  baby  was  six  weeks 


ATHREPSIA   INFANTUM.  315 

old;  the  child  nursed  well,  gained  6  ounces  the  first  week, 
8  ounces  the  second,  and  weighed  14  pounds  when  it  was 
four  and  a  half  months  old.  The  child  improved  until  it 
was  seven  months  old,  when  suddenly  the  weight  remained 
stationary.  A  specimen  of  breast-milk  was  sent  to  John 
S.  Adriance,  the  chemist  of  the  Nursery  and  Child's  Hos- 
pital, who  found  the  following  percentages: — 

Fat    2.000 

Sugar   7.431 

Proteids   0.882 

Ash   0.162 

Specific  gravity,  1031;    reaction,  alkaline. 

It  is  very  evident  that  the  deficiency  in  albuminoids 
or  proteids  was  accountable  for  the  stationary  weight.  The 
child  did  not  gain  an  ounce  in  one  month.  We  discharged 
the  wet-nurse,  and  resorted  to  hand-feeding,  when  the 
child's  general  condition  changed,  and  she  is  bright  and 
well  to-day. 

In  another  instance,  a  child  had  been  nursed  by  its 
own  mother  for  three  months,  and  had  gained  in  weight 
regularly  at  the  rate  of  6  and  7  ounces  per  week;  the 
stools  were  normal  in  quantity  and  quality,  when  sud- 
denly the  child  appeared  to  be  colicky,  was  restless  at 
night,  had  green  stools,  and  did  not  appear  to  thrive.  For 
two  consecutive  weeks  the  child  did  not  gain  in  weight, 
and  a  specimen  of  breast-milk  was  sent  to  the  Pediatrics 
Laboratory.  Mr.  E.  W.  Bailey,  the  chemist,  examined 
the  specimen,  with  the  following  result: — 

Fat    2.43 

Proteids   1.25 

Sugar   6.51 

Ash   0.20 

Total  solids   10.39 

Specific  gravity,  1027;    reaction,  slightly  alkaline. 


316  INFANT-FEEDING. 

The  percentage  of  fat  and  proteids  is  so  low  that  it 
was  very  plain  to  me  why  this  child  did  not  increase  in 
weight.  On  putting  the  child  on  an  oatmeal  and  top- 
milk  mixture,  the  digestion  improved,  the  child's  sleep 
was  better,  and  the  weight  increased. 

Another  case  was  that  of  a  nursling,  brought  to  me 
with  a  history  of  excessive  crying,  greenish  stools,  cheesy 
curd  in  the  stools,  vomiting,  restlessness,  and  a  general 
condition  of  malassimilation;  I  asked  for  a  specimen  of 
breast-milk,  which  Mr.  Bailey  kindly  examined,  with  the 
following  result : — ■ 

Fat    4.32 

Sugar 6.22 

Proteids   1.80 

Ash   0.19 

Total  solids 12.53 

Reaction,  neutral. 

The  general  history  of  the  case  showed  that  the  child 
was  fed  every  time  it  cried,  and  thus  it  was  evident  that 
overfeeding  was  the  real  cause  of  the  trouble  in  this  case, 
for  I  learned  that  the  child  frequently  nursed  for  hours 
at  the  breast,  and  was  also  allowed  to  go  to  sleep  with  the 
nipple  in  its  mouth.  Whenever  the  child  cried  it  was  fed, 
frequently  as  often  as  every  half-hour,  so  that  in  this  case, 
while  the  quality  of  the  breast-milk  was  absolutely  nor- 
mal, as  demonstrated  by  the  chemical  examination,  it  re- 
quired only  the  judicious  interval  for  feeding  to  give  the 
child's  stomach  proper  time  for  the  assimilation  of  its 
food. 


CHAPTER  XLYIII. 

Infant-feeding  in  Summer  Complaint. 

The  successful  management  of  a  case  of  summer  com- 
plaint affecting  the  stomach  and  bowels  depends  largely 
on  the  feeding.  We  know  that  when  food  is  given  which 
is  improper  in  quality  or  quantity, — in  other  words,  when 
dietetic  errors  have  been  committed, — then  the  child  will 
suffer  with  gastro-intestinal  or  gastric  disorders.  The 
nursing  baby,  fed  exclusively  from  the  breast,  is  usually 
exempt  from  summer  complaint,  unless  it  is  fed  irregu- 
larly or  if  the  milk  is  of  an  improper  quality.  Thus  we 
know  that,  when  breast-milk  contains  large  quantities  of 
colostrum-corpuscles,  such  milk  has  a  decided  laxative 
effect.  What  has  already  been  said  in  regard  to  the  proper 
supervision  of  breast-milk,  in  the  chapters  on  "Breast- 
feeding" and  "Wet-nursing,"  must  be  emphasized  when 
it  is  desired  to  feed  an  infant  during  the  summer  months. 

The  depressing  effect  of  extreme  heat  in  midsummer 
naturally  tends  to  lower  the  vitality  of  the  infant.  We 
must  not,  therefore,  be  surprised  to  find  that  an  appetite, 
which  has  been  unusually  good  heretofore,  suddenly  di- 
minishes. When  the  infant  shows  loss  of  appetite,  noth- 
ing will  tone  up  the  stomach  and  bowels  more  quickly 
than  a  sudden  change  of  air  from  the  city  to  the  sea- 
shore. If,  in  spite  of  the  change  of  air  to  the  sea-shore, 
the  infant  still  continues  to  vomit  or  to  have  loose,  green- 
ish, or  "muddy"  stools  (the  latter  are  usually  found  in 
that  most  frequent  form  of  summer  complaint  known  as 
"colitis"),  then  the  breast-feeding  should  be  stopped  and 
the  stomach  given  complete  rest  for  twenty-four  or  forty- 
eight  hours.  Substitute  food  such  as  barley-water,  rice- 
water,  albumin-water,  or  weakened  mixed  tea  to  which 

(317) 


318 


INFANT-FEEDING. 


the  white  of  a  raw  egg  has  been  added;  Uiese  can  be  given 
in  teaspoonful  doses.  Steak-juice  can  also  be  advanta- 
geously given  at  regular  intervals  of  every  three  to  four 
hours.  In  this  manner  we  remove  milk  from  our  dietary, 
for  the  time  being,  and  give  the  above  liquid  nourish- 
ment, which  is  easily  absorbed.  It  is  a  good  plan  to 
dextrinize  all  the  cereals,  if  the  child  shows  a  tendency 
toward  vomiting  after  the  milk  has  been  withdrawn. 
When  severe  vomiting  persists,  in  spite  of  the  withdrawal 
of  milk  and  the  substitution  of  the  cereals  and  the  white 
of  egg  above  mentioned,  then  absolute  rest  of  the  stomach 
must  be  insisted  upon  and  rectal  feeding  substituted  there- 
for. 

RACAHOUT    POWDER. 

1  pound  of  rice-powder.  2  ounces  of  arrowroot. 

1  ounce  of  powdered  salep.  2  ounces  of  sugar  of  milk. 

1  pound  of  cocoa.  1  vanilla-bean. 

1  pound  of  confectioners'  xxx  sugar. 

Mix  and  thoroughly  rub  together,  put  into  glass  jars,  and 
fasten.  Boil  1  teaspoonful  with  4  ounces  of  water.  Feed  every  three 
or  four  hours. 

RECTAL    ALIMENTATION. 

Always  cleanse  the  rectum  by  using  an  enema  of 
soap-water  or  glycerin  and  water,  in  the  proportion  of  4 
ounces  of  glycerin  to  a  pint  of  warm  water,  at  a  tempera- 
ture of  100°  F.  Following  this  rectal  cleansing,  pepto- 
nized milk  "thoroughly  peptonized,"  or  yolk  of  an  egg 
with  starch-water,  or  beef-blood  and  starch-water,  should 
be  slowly  injected.  More  than  2  ounces  should  not  be 
used  for  one  feeding  enema.  This  method  of  feeding  has 
already  been  described  in  the  chapter  on  the  "Feeding  of 
Diphtheria-Intubation  Cases." 

DIETETIC    MANAGEMENT    OF    A    BOTTLE-FED    BABY. 

Discontinue  all  kinds  of  food  which  were  given  at 
the  beginning  of  the  summer  complaint.     For  example,  if 


INFANT-FEEDING    IN    SUMMER    COMPLAINT.  319 

milk  has  been  given,  it  must  be  discontinued,  and  in  its 
place  a  food  which  is  more  easily  assimilated  must  be 
supplied.  Such  foods  are  barley-water,  rice-water,  farina- 
water,  sago-water  or  arrowroot-water.  These  are  very 
easily  made  by  adding  a  tablespoonful  of  either  one  of 
the  above-mentioned  cereals  to  a  pint  of  water  and  boil- 
ing the  same  for  about  one-half  hour;  strain  through  a 
cheese-cloth,  and  then  add  enough  water  to  make  1  pint. 
This  proportion  will  keep  as  a  stock  solution  for  one  or 
two  days,  if  put  into  a  refrigerator.  In  hot  weather  pre- 
pare daily. 

In  feeding  we  use  3  to  6  ounces,  to  which  a  pinch  of 
salt  and  some  sugar  have  been  added,  and  warm  the  same 
to  body-heat  immediately  before  feeding.  In  making  rice- 
water  a  much  longer  time  is  required  to  boil  the  same. 
For  further  particulars  we  refer  to  the  dietary.  The 
quantity  to  be  fed  depends  on  the  age  of  the  child;  thus, 
if  the  child  has  received  6  ounces  of  milk  at  one  feeding, 
prior  to  its  attack  of  summer  complaint,  then  a  good  plan 
is  to  substitute  6  ounces  of  barley-water,  rice-water,  or 
sago-water  for  the  6  ounces  of  milk.  It  is  also  a  good 
plan  to  allow  a  larger  feeding  interval  during  an  attack 
of  summer  complaint,  and  to  give  the  stomach  and  bowels 
less  work.  Hence  my  plan  has  been  to  feed  every  four 
hours,  if  the  interval  prior  to  the  attack  has  been  every 
three  hours. 

Thirst  requires  careful  management.  If  the  child  is 
very  thirsty  it  is  a  good  plan  to  give  plain  boiled  water, 
or  to  add  the  white  of  a  raw  egg  ("albumin-water").  If 
the  child  is  over  one  year  old,  a  few  drops  of  expressed 
meat-juice,  made  by  broiling  a  steak  over  a  fire  and  ex- 
pressing the  juice  in  a  lemon-squeezer  or  meat-press,  is 
advantageous.  When  the  infant's  condition  is  normal 
and  its  digestive  power  is  strengthened,  then  we  can  grad- 
ually return  to  Nature's  remedy,  namely:    milk-feeding. 

Every  physician  knows  how  difficult  it  is  to  keep  milk 
fresh  and  pure  during  the  hot  weather,  and,  therefore, 


320  INFANT-FEEDING. 

in  summer  it  is  advisable  to  pasteurize  or  sterilize  the 
milk  for  about  fifteen  minutes,  as  soon  as  it  is  received 
from  the  dairy,  and  then  to  keep  it  in  the  refrigerator 
until  it  is  time  for  feeding.  Thus  we  prevent  not  only 
the  formation  of  the  germs,  but  also  the  development  of 
toxins,  which  are  so  death-dealing  in  midsummer. 

The  most  vital  point  to  be  considered  in  the  man- 
agement of  summer  complaint,  next  to  the  diet,  is  fresh 
air,  and  hence,  unless  children  can  be  given  the  benefit  of 
daily  excursions  to  the  sea-shore  or  to  the  mountains,  and 
can  be  removed  from  unsanitary  and  improper  hygienic 
surroundings,  we  must  not  look  for  permanent  results. 

NURSING    INFANT. 

If  a  nursing  infant  has  summer  complaint,  then  it  is 
advisable  to  stop  nursing.  Frequently  giving  the  stom- 
ach absolute  rest  for  one-half  or  one  whole  day  will  work 
wonders. 

The  breast-milk  should  be  drawn  with  the  aid  of  a 
breast-pump  at  regular  intervals,  as  though  the  baby  were 
nursing,  and  the  milk  should  be  thrown  away.  The  same 
rule  applies  to  the  nursing  baby  as  applies  to  the  bottle- 
fed  baby.  Thus  milk  must  be  temporarily  withdrawn 
and  other  feeding  substituted. 


DIETABY. 

Almond-milk. 

Take  2  ounces  of  sweet  almonds,  scald  them  with 
boiling  water;  after  a  few  moments  express  them  from 
the  hulls;  then  pour  the  hot  water  away.  Put  the 
blanched  almonds  into  a  mortar  and  pound  them  thor- 
oughly, and  add  either  2  ounces  of  milk  or  2  ounces  of 
plain  water.  After  this  is  thoroughly  mixed,  it  is  to  be 
strained  through  cheese-cloth,  and  the  strained  liquid  will, 
be  the  almond-milk. 

Keller's  Malt-soup. 

Take  of  wheat-flour  50.0  (about  2  ounces).  To  this 
add  11  ounces  of  milk.  Soak  the  wheat-Hour  thoroughly, 
and  rub  it  through  a  sieve  or  strainer. 

Put  into  a  second  dish  20  ounces  of  water,  to  which 
add  3  ounces  of  malt-extract;  dissolve  the  above  at  a  tem- 
perature of  about  120°  F.,  and  then  add  10  cubic  centi- 
metres (about  2  1/2  drachms)  of  11-per-cent.  potassium 
bicarbonate  solution.  Finally  mix  all  of  the  above  ingre- 
dients, and  boil. 

This  gives  a  food  containing: — 

Albuminoids     2.0  per  cent. 

Fat   1.2  per  cent. 

Carbohydrates  12.1  per  cent. 

There  are  in  this  mixture: — 

Vegetable  proteids   0.9  per  cent. 

The  wheat-flour  is  necessary,  as  otherwise  the  malt- 
soup  would  have  a  diarrhceal  tendency.      The  alkali  is 

21  (321) 


322  INFANT-FEEDING. 

added  to  neutralize  the  large  amount  of  acid  generated 
in  sick  children.  Biedert  emphasizes  the  importance  of 
giving  fat,  rather  than  reducing  its  quantity,  in  poorly 
nourished  children,  and  cites  the  assimilability  of  his 
cream-mixture  or  of  breast-milk  in  under-fed  children  as 
proof  of  his  assertions.  The  author  has  used  this  malt- 
soup  most  successfully  in  the  treatment  of  athrepsia 
(marasmus)  cases  in  which  the  children  were  simply 
starved. 

Junket  of  Milk  and  Egg. 

Beat  1  egg  to  a  froth  and  sweeten  with  2  teaspoonfuls 
of  white  sugar.  Add  this  to  1/2  pint  of  warm  milk;  then 
add  1  teaspoonf ul  of  essence  of  pepsin  (Tairchild) ;  let  it 
stand  till  it  is  curdled.  The  above  is  useful  in  typhoid 
and  similar  wasting  diseases. 

Plain  Junket. — This  is  sometimes  called  "curds  and 
whey."  Take  1/2  pint  of  fresh,  raw  milk,  and  heat  it 
lukewarm.  Then  add  a  teaspoonful  of  Fairchild's  essence 
of  pepsin,  and  stir  the  mixture  thoroughly.  Pour  into 
custard  cups,  and  let  it  stand  until  firmly  curdled.  The 
flavor  can  be  improved  by  adding  some  essence  of  lemon 
or  cinnamon  or  grated  nutmeg. 

When  the  essence  of  pepsin  (Fairchild's)  cannot  be 
had,  or  for  convenience  in  traveling,  the  author  has  used 
Hansen's  junket  tablets,  which  will  give  similar  results 
as  the  liquid  essence  of  pepsin. 

Peetogenic  Milk-powdek. 

The  pancreas  ferment  trypsin  is  known  to  have  a 
remarkable  affinity  toward  milk,  digesting  its  casein  with 
great  rapidity  without  altering  its  other  elements,  and 
without  rendering  the  milk  repulsive.  When  milk  is  so 
treated  it  is  known  as  peptonized  milk.  Through  the  ex- 
pert investigation  of  the  well-known  chemist  Dr.  Albert 
Leeds,  the  peptogenic  milk-powder  was  found  to  yield  a 
milk  which  was  similar  to  a  humanized  milk.    The  author 


DIETARY.  323 

has  had  some  experience  in  the  modification  of  cows'  milk 
by  the  addition  of  peptogenic  milk-powder,  and  can  safely 
say  that  it  is  one  of  the  most  valuable  additions  to  our 
infant-feeding  that  we  possess. 

There  are  three  steps  necessary  for  the  preparation 
of  "humanized  milk"  in  using  the  peptogenic  milk- 
powder  : — 

1.  To  prepare — with  peptogenic  powder,  cows'  milk, 
water,  and  cream — a  mixture  which  has  the  quantitative 
composition  of  average  human  normal  milk. 

2.  To  subject  this  mixture  to  the  action  of  the  di- 
gestive principle  by  which  the  albuminoids  (casein,  etc.) 
are  converted  into  such  form  as  to  become  identical  with 
those  of  human  milk. 

3.  To  then  destroy,  the  digestive  ferment  by  simply 
raising  the  temperature  of  the  milk  to  the  boiling-point. 
This  heat  also  destroys  the  bacteria,  and  renders  the  milk 
practically  sterile  during  the  time  required  for  its  use: 
twenty-four  hours. 

DIRECTIONS    FOR    "HUMANIZED    MILK." 

No.  1. — For  the  daily  food  of  a  healthy  infant:  Put 
into  a  clean  graniteware  or  porcelain-lined  saucepan  one 
measure  (which  accompanies  each  bottle)  of  peptogenic 
powder;  add  to  this  1/2  pint  of  cold  water,  1/2  pint  of 
cold,  fresh  milk,  and  4  tablespoonfuls  of  cream.  Place 
the  saucepan  on  a  hot  range  or  gas-stove,  and  heat,  with 
constant  stirring,  until  the  mixture  boils.  The  heat  should 
be  so  applied  as  to  make  the  milk  boil  in  ten  minutes. 
Keep  in  a  clean,  well-corked  bottle,  in  a  cool  place.  When 
needed,  shake  the  bottle,  and  pour  out  the  desired  por- 
tion, and  warm  the  same  before  feeding. 

No.  2. — Specially  designed  for  children  with  feeble 
digestion,  or  when  the  stomach  and  bowels  are  disordered, 
as  in  catarrhal  conditions.  Put  into  a  clean  bottle  1  meas- 
ure of  the  peptogenic  powder,  1/2  pint  of  cold  water,  1/2 
pint  of  cold,  fresh  milk,  and  4  tablespoonfuls  of  cream. 


324  INFANT-FEEDING. 

Shake  well,  place  the  bottle  in  a  pail  or  tin  kettle  of  water, 
holding  a  gallon,  as  hot  as  can  be  borne  by  the  hand 
(115°  F.),  and  keep  the  bottle  there  for  thirty  minutes. 
Then  pour  all  into  a  saucepan,  and  quickly  heat  to  boiling- 
point,  with  constant  stirring.  The  bottles  of  the  pepto- 
genic  milk-powder  made  by  Fairchild  Brothers  &  Foster 
have  a  metal  screw-cap,  which  is  the  measure  above  al- 
luded to.  If  the  infant's  digestive  powers  are  still  weaker, 
or  if,  after  feeding  the  last-named  formula,  vomiting 
takes  place,  then  it  is  safer  to  use: — 

One  measure  of  peptogenie  milk-powder. 
One-third  pint  of  raw  milk. 
Two-thirds  pint  of  water. 

Mix,  heat,  and  boil,  as  described  above,  and  it  is  ad- 
visable to  feed  at  longer  intervals;  for  example,  every 
three  or  four  hours,  if  the  infant  has  previously  been  fed 
every  two  or  three  hours.  Never  use  the  balance  left  over 
in  a  feeding-bottle  after  the  infant  has  sucked,  but  al- 
ways give  a  fresh  quantity  of  food  for  each  meal,  and 
whatever  the  baby  leaves  should  be  invariably  thrown 
away. 

The  weight  and  the  stools  are  important  factors  in 
judging  when  to  increase  the  quantity  of  milk  and  cream, 
or  vice  versa. 

Pkedigested  Food. 

To  Prepare  Rice. — Take  1/4  pound  of  rice,  add  water, 
and  boil  until  soft.  Break  grains  by  passing  through  a 
colander.  Take,  of  bana-diastase  (American  Ferment 
Company),  8  grains,  and  dissolve  in  1  ounce  of  water 
and  add  to  the  rice,  which  must  be  kept  warm,  but  not 
hot.  Let  stand  for  two  hours  at  a  temperature  of  105° 
F.  When  rice  is  thoroughly  softened,  season  with  salt, 
sparingly.  Add  a  little  cream  if  desired.  Serve  hot  or 
cold. 

To  Prepare  Beans  or  Peas.  —  Take  1/4  pound  of 
beans  or  peas,  add  water,  and  boil  until  soft.     Remove 


DIETARY.  325 

skins  by  passing  through  a  colander.  Take  of  caroid 
powder,  4  grains,  and  of  bana-diastase,  8  grains;  dissolve 
in  1  ounce  of  water.  Add  to  the  beans,  which  must  be 
kept  warm,  but  not  hot.  Let  stand  for  one  hour  at  a 
temperature  of  105°  F.  Season  slightly  with  salt.  Beans 
and  peas  require  the  double  action  of  proteolytic  and 
starch-converting  ferments,  as  they  are  composed  largely 
of  proteids,  as  well  as  starch. 

Peptonized  Milk. 

Into  a  clean,  quart  bottle  put  the  powder  contained 
in  one  of  the  Fairchild  peptonizing  tubes,  and  a  teacupful 
(gill)  of  cold  water;  shake,  then  add  a  pint  of  fresh,  cold 
milk,  and  shake  the  mixture  again.  Place  the  bottle  in 
water  as  hot  as  the  whole  hand  can  be  held  in  it  with- 
out discomfort.     (About  115°  F.) 

Keep  the  bottle  there  five  or  ten  minutes  as  directed. 

At  the  end  of  that  time  put  the  bottle  on  ice  at  once 
to  check  further  digestion  and  keep  the  milk  from  spoil- 
ing. 

Place  the  bottle  directly  in  contact  with  the  ice. 

The  degree  of  digestion  is  very  simply  regulated  by 
the  length  of  time  in  which  the  milk  is  kept  warm. 

partially  peptonized  milk. 

Put  into  a  clean  agateware  or  porcelain-lined  sauce- 
pan the  powder  contained  in  one  of  the  Fairchild  pep- 
tonizing tubes,  and  a  teacupful  (gill)  of  cold  water;  stir 
well ;  then  add  a  pint  of  cold,  fresh  milk.  Heat  with  con- 
stant stirring  until  the  mixture  boils.  The  heat  should 
be  so  applied  that  the  milk  will  come  to  a  boil  in  ten  min- 
utes. When  cool,  strain  into  a  clean  bottle,  cork  well,  and 
keep  in  a  cold  place.  When  needed,  shake  the  bottle, 
pour  out  the  required  portion,  and  serve  cold  or  hot,  as 
directed  by  the  physician  in  charge.  Milk  so  prepared 
will  not  become  bitter. 


326  INFANT-FEEDING. 

IMMEDIATE    PROCESS. 

Put  2  tablespoonfuls  (1  ounce)  of  cold  water  in  a 
goblet  or  glass ;  dissolve  in  this  one-fourth  of  the  contents 
of  a  peptonizing  tube;  add  8  tablespoonfuls  (4  ounces) 
of  warm  milk;    drink  immediately,  sipping  slowly. 

If  half  a  pint  of  milk  is  required,  double  the  propor- 
tions of  water,  peptonizing  powder,  and  milk. 

COLD    PROCESS. 

Into  a  clean,  quart  bottle  put  the  powder  contained 
in  1  of  the  Fairchild  peptonizing  tubes,  and  a  teacupful 
(gill)  of  cold  water;  shake,  then  add  a  pint  of  fresh,  cold 
milk ;  shake  the  mixture  again  and  immediately  place  the 
bottle  on  ice,  without  subjecting  it  to  the  water-bath  or 
any  heat.  Place  the  bottle  directly  in  contact  with  the 
ice. 

When  needed,  shake  the  bottle,  pour  out  the  required 
portion,  and  use  in  the  same  manner  as  ordinary  milk. 

Peptonized  Milk-gruel. 

Thick,  well-boiled,  hot  gruel  1/2  pint. 

Milk,  fresh,  cold   1/2  pint. 

Mix  and  strain  into  a  small  pitcher  or  jar,  and  im- 
mediately add  the  contents  of  1  Fairchild  peptonizing 
tube;  mix  well.  Let  it  stand  in  the  hot  water-bath,  or 
warm  place,  for  five  minutes,  then  put  in  a  clean  bottle 
and  place  on  ice.     Serve  hot  or  cold. 

Gruel  made  from  arrowroot,  flour,  barley,  oatmeal, 
etc.,  will  serve  for  the  purpose.  In  each  instance  the 
farinaceous  material  should  be  boiled  with  water  until 
the  starch-granules  have  been  thoroughly  swollen,  broken 
up,  and  incorporated  with  the  water. 

Whey. 

To  make  whey  take  1/2  pint  of  fresh  milk,  heated 
lukewarm,  not  warmer  than  can  be  agreeably  borne  by 


DIETAKT.  327 

the  mouth  (about  115°  F.);  add  1  teaspoonful  of  Fair- 
child's  essence  of  pepsin,  and  stir  just  enough  to  mix. 
Pour  into  custard-cups;  let  it  stand  until  firmly  curdled; 
then  beat  up  with  a  fork  until  the  curd  is  finely  divided; 
now  strain,  and  the  whey  is  ready  for  use. 

Whey  prepared  from  fresh  cows'  milk  should  be  alka- 
line and  contain 

From  0.8  to  1  per  cent,  of  lactaltmmin. 
0.03  per  cent,  of  casein. 
1.0     per  cent,  of  fat. 

When  such  whey  is  added  to  milk  for  an  infant  under 
6  weeks  take,  of  whey,  2  parts;  milk,  1  part.  This  can 
be  increased  until  equal  parts  of  milk  and  whey  are  used 
for  a  child  several  months  old. 

Preparation  of  Sweet  Whey.  —  Sweet  whey  is  best 
made  by  the  following  method:  For  each  pint  of  whey 
needed  take  1  pint  of  whole  fresh  milk  or  fat-free  milk, 
heated  to  37.7°  C.  (100°  F.),  and  add  8  cubic  centime- 
tres (2  drachms)  of  the  essence  of  pepsin  or  some  of  the 
preparations  of  liquid  rennet.  This  will  precipitate  the 
casein  in  the  form  of  a  curd,  which  is  then  broken  up 
with  a  fork;  the  fluid  which  remains  is  the  whey.  This 
is  strained  through  two  thicknesses  of  boiled  cheese-cloth 
and  one  thickness  of  absorbent  cotton  and  slowly  cooled 
to  a  temperature  of  10°  C.  (50°  F.),  and  kept  on  ice 
until  needed.  If  the  whey  is  to  be  mixed  with  cream, 
it  must  first  be  heated  to  65.5°  C.  (150°  F.),  in  order  to 
kill  the  rennet  enzyme.  Whey  mixtures  should  not  be 
heated  above  68.3°  C.  (155°  F.)  if  one  wishes  to  keep 
safely  under  the  coagulation-point  of  the  lactalbumin. 

Junket  (Curds  and  Whey). 

Junket. — Take  1/2  pint  of  fresh  milk,  heated  luke- 
warm— not  warmer  than  can  be  agreeably  borne  by  the 
mouth  (about  115°  F.);   add  1  teaspoonful  of  Fairchild's 


328  INFANT-FEEDING. 

essence  of  pepsin,  and  stir  just  enough  to  mix.  Pour  into 
custard-cups;  let  it  stand  until  firmly  curdled;  may  be 
served  plain  or  with  sugar  and  grated  nutmeg. 

An  egg  beaten  to  a  froth  and  sweetened  with  2  tea- 
spoonfuls  of  sugar  may  previously  be  added  to  the  half- 
pint  of  milk,  forming  a  highly  nutritious  and  smooth  jelly. 
The  essence  will  curdle  milk  with  egg  as  readily  as  plain 
milk. 

Whey. — Curdle  warm  milk  with  the  essence  of  pepsin 
as  above  directed;  then  beat  up  with  a  fork  until  the  curd 
is  finely  divided;  now  strain,  and  the  whey  is  ready  for 
use. 

Whey  is  a  highly  nutritious  fluid  food  peculiarly  use- 
ful in  many  ailments  and  always  valuable  as  a  means  of 
variety  in  diet  for  the  sick.  It  is  frequently  resorted  to 
as  a  food  for  infants  to  tide  over  periods  of  indigestion, 
summer  complaints,  etc. 

Gum- Arabic  Water. 

Dissolve  1  ounce  of  gum  arabic  in  a  pint  of  boiling 
water;  add  2  tablespoonfuls  of  sugar,  a  wineglassful  of 
sherry,  and  the  juice  of  a  large  lemon.    Cool  and  add  ice. 

Lime-water. 

Pour  2  quarts  of  water  over  fresh  unslaked  lime  the 
size  of  a  walnut;  stir  until  slaked,  and  let  stand  until 
clear;  then  bottle.  Lime-water  is  often  ordered  with 
milk  to  neutralize  acidity  of  the  stomach. 

Tamarind-water. 

A  very  refreshing  drink  may  be  made  by  adding  1 
pint  of  hot  water  to  1  tablespoonful  of  preserved  tama- 
rinds, and  setting  aside  to  cool. 

Lemonade. 

Squeeze  the  juice  from  1  lemon.  Add  2  tablespoon- 
fuls of  sugar  and  1  cup  of  water.     Strain  and  serve. 


DIETARY.  329 

Milk  and  Albumin. 

Put  into  a  clean  quart  bottle  1  pint  of  milk,  the 
whites  of  2  eggs,  and  a  small  pinch  of  salt.  Cork  and 
shake  hard  for  five  minutes. 

Milk-punch. 

Take  1/2  pint  of  fresh,  cold  milk  and  add  2  teaspoon- 
fuls  of  sugar,  and  stir  well  until  dissolved;  then  add  1 
ounce  of  either  brandy  or  sherry  wine. 

Orangeade. 

Substitute  orange-juice  for  that  of  lemon  in  the  recipe 
for  "Lemonade." 

Tea. 

Scald  out  the  teapot  and  put  in  the  tea,  using  1  tea- 
spoonful  for  1  cupful.  Pour  on  lolling  water,  and  let 
teapot  stand  four  or  five  minutes.  If  allowed  to  stand 
too  long,  the  tannin  in  the  tea  is  developed,  which  not 
only  darkens  the  tea,  but  also  renders  it  hurtful. 

Albumin-water. 

Stir  the  whites  of  2  eggs  into  1/2  pint  of  ice-water, 
without  beating;  add  enough  salt  or  sugar  to  make  it 
palatable. 

Apple-water. 

Slice  into  a  pitcher  1/2  dozen  juicy  sour  apples;  add 
1  tablespoonful  of  sugar,  and  pour  over  them  1  quart  of 
boiling  water.    Cover  closely  until  cold;   then  strain. 

Toast-water. 

Equal  measures  of  stale  bread,  toasted,  and  boiling 
water.  Cut  the  bread  in  thin  slices,  put  into  pan,  and 
dry  thoroughly  in  a  slow  oven  until  crisp  and  brown. 
Break  in  pieces,  add  water,  and  let  stand  one  hour.  Strain 
and  season.     Serve  hot  or  cold. 


330  infant-feeding. 

Barley-water. 

■Wash  2  ounces  (wineglassful)  of  pearl  barley  with 
cold  water.  Boil  it  five  minutes  in  fresh  water;  throw 
both  waters  away;  pour  on  2  quarts  boiling  water;  boil 
down  to  1  quart.  Flavor  with  thinly  cut  lemon-rind;  add 
sugar  to  taste.    Do  not  strain  unless  at  patient's  request. 

How  to  Prepare  Cocoa  and  Chocolate, 
cocoa. 

For  each  large  cup  take  a  teaspoonful  of  cocoa  and 
a  teaspoonful  of  sugar;  mix  to  a  paste  with  a  little  boil- 
ing water  or  milk;  add  balance  of  milk  or  milk  and 
water,  as  richness  is  desired.  Let  it  boil  a  minute,  as 
boiling  improves  it. 

CHOCOLATE    (UNSWEETENED). 

For  each  breakfastcup  take  1  division,  break  in  small 
pieces,  and  allow  to  melt;  add  milk  or  milk  and  water, 
as  richness  is  desired.  Stir  constantly.  Bring  to  a  boiling- 
point  and  set  aside  to  simmer.     Sugar  to  taste. 

CHOCOLATE    (SWEETENED). 

Take  1  section  of  a  half-pound  cake  for  each  cup. 
Break  in  pieces  in  dish  and  allow  to  melt  without  burn- 
ing. Place  the  dish  over  a  slow  fire;  add  the  necessary 
quantity  of  water  and  milk.  A  few  minutes'  boiling  will 
suffice.    Stir  frequently.    Allow  to  simmer  a  few  minutes. 

"When  milk  is  contra-indicated,  boil  the  cocoa  or  choco- 
late with  water  only. 

Coffee  (French). 

Some  persons  prefer  filtered  to  boiled  coffee.  Filtered 
coffee  is  best  made  in  a  French  biggin,  consisting  of  two 
tin  vessels,  one  fitting  into  the  other,  the  upper  one  being 
supplied  with  strainers.     The  coffee,  being  very  finely 


DIETARY.  331 

ground,  is  placed  in  this  utensil,  and  the  boiling  water 
allowed  to  slowly  percolate  through  it.  The  pot  should 
be  set  where  it  will  keep  hot,  but  not  boil,  until  the  water 
has  gone  through.  Pouring  it  through  the  coffee  a  second 
time  will  make  it  stronger,  but  it  loses  in  flavor.  Cafe 
noir  is  always  made  in  this  way. 

Nutritious  Coffee. 

Dissolve  a  little  isinglass  or  gelatin  (Knox)  in  water; 
put  1/2  ounce  of  freshly  ground  coffee  into  a  saucepan 
with  1  pint  of  new  milk,  which  should  be  nearly  boiling 
before  the  coffee  is  added;  boil  both  together  for  three 
minutes;  clear  it  by  pouring  some  of  it  into  a  cup  and 
dashing  it  back  again;  add  the  isinglass,  and  leave  the 
coffee  on  the  back  part  of  the  range  for  a  few  minutes 
to  settle.  Beat  up  1  egg  in  a  breakfastcup,  and  upon  it 
pour  the  coffee;   if  preferred,  drink  without  the  egg. 

Eggnog. 

Scald  some  milk  by  putting  it,  contained  in  a  jug, 
into  a  saucepan  of  boiling  water,  but  do  not  allow  the 
milk  to  boil.  When  cold,  beat  up  a  fresh  egg  with  a 
fork  in  a  tumbler  with  some  sugar;  beat  to  a  froth,  add 
a  dessertspoonful  of  brandy,  and  fill  up  tumbler  with 
the  scalded  milk. 

Soft  Custard. 

Take  of  cornstarch  2  tablespoonfuls  to  1  quart  of 
milk;  mix  the  cornstarch  with  a  small  quantity  of  the 
milk,  and  flavor;  beat  up  2  eggs.  Heat  the  remainder  of 
the  milk  to  near  boiling;  then  add  the  mixed  corn,  the 
eggs,  4  tablespoonfuls  of  sugar,  a  little  butter,  and  salt. 
Boil  the  custard  two  minutes,  stirring  briskly. 

Calf's-Foot  Jelly. 

Thoroughly  clean  2  feet  of  a  calf,  cut  into  pieces,  and 
stew  in  2  quarts  of  water  until  reduced  to  1  quart;   when 


332  INFANT-FEEDING. 

cold,  take  off  the  fat  and  separate  the  jelly  from  trie  sedi- 
ment. Then  put  the  jelly  into  a  saucepan,  with  white 
wine  and  brandy  and  flavoring  to  taste,  with  the  shells 
and  whites  of  4  eggs  well  mixed  together;  boil  for  a 
quarter  of  an  hour,  cover  it,  and  let  it  stand  for  a  short 
time,  and  strain  while  hot  through  a  flannel  bag  into  a 
mold. 

Tapioca-cream. 

Take  1  pint  of  milk,  2  tablespoonfuls  of  tapioca,  2 
tablespoonfuls  of  sugar,  1  saltspoonful  of  salt,  and  2  eggs. 
Wash  the  tapioca.  Add  enough  water  to  cover  it,  and  let 
it  stand  in  a  warm  place  until  the  tapioca  has  absorbed 
the  water.  Then  add  the  milk  and  cook  in  a  double  boiler, 
stirring  often  until  the  tapioca  is  clear  and  transparent. 
Beat  the  yolks  of  the  eggs.  Add  the  sugar  and  salt  and 
the  hot  milk.  Cook  until  it  thickens.  Remove  from  the 
fire.  Add  the  whites  of  the  eggs,  beaten  stiff.  When 
cold,  add  1  teaspoonful  of  vanilla. 

Toasted  Bread  (Toast,  Dry). 

Cut  thin  slices  of  bread  into  strips,  toast  carefully 
and  evenly  without  breaking,  slightly  butter,  and  serve 
immediately  on  a  hot  plate. 

Cream-toast. 

Take  1  cupful  of  cream,  1  saltspoonful  of  salt,  2  slices 
of  dry  toast ;  or  make  the  same  as  milk-toast,  using  cream 
in  place  of  the  milk.  If  preferred,  the  slices  of  toast  may 
be  first  dipped  in  hot,  salted  water. 

Egg-toast. 

Take  1  egg,  1  saltspoonful  of  salt,  1  cupful  of  milk, 
6  slices  of  bread.  Beat  the  egg  lightly ;  add  the  salt  and 
milk.  Soak  slices  of  bread  in  this  until  soft.  Butter  a 
hot  griddle;   put  on  the  bread;   when  one  side  is  brown, 


DIETARY. 


333 


put  a  bit  of  butter  on  each  slice,  then  turn  and  brown  the 
other  side.     Serve  with  sugar  and  cinnamon. 

Milk-toast. 

Take  1  cupful  of  milk,  1/2  tablespoonful  of  corn- 
starch, V2  tablespoonful  of  butter,  2  slices  of  dry  toast,  1 
saltspoonful  of  salt.  Scald  the  milk.  Melt  the  butter  in 
a  saucepan;  when  hot  and  bubbling,  add  the  cornstarch. 
Pour  in  the  hot  milk  slowly,  beating  all  the  time  until 
smooth.  Let  it  boil  up  once.  Then  add  the  salt.  Toast 
2  slices  of  bread.  Pour  the  thickened  milk  over  the  slices. 
Let  it  stand  five  minutes.     Serve. 

Baked  Apples. 

Core  and  pare  2  tart  apples;  fill  the  core-holes  with 
sugar;  grate  over  the  apples  a  little  nutmeg;  add  a  little 
water  to  baking-pan  and  put  in  oven  and  bake  until  the 
apples  are  soft.  Serve  with  rich  milk  or  cream.  Sprinkle 
with  icing  sugar,  if  not  sweet  enough. 

Mutton-soup. 

Cut  up  fine  2  pounds  of  lean  mutton,  without  fat  or 
skin.  Add  1  tablespoonful  of  barley, .  1  quart  of  cold 
water,  and  a  teaspoonful  of  salt.  Let  it  boil  slowly  for 
two  hours.  If  rice  is  used  in  place  of  barley,  soak  the  rice 
in  water  over  night,  if  it  is  to  be  boiled  in  the  morning. 

"White  Celery  Soup. 

Take  1/2  pint  of  strong  beef -tea;  add  an  equal  quan- 
tity of  boiled  milk,  slightly  and  evenly  thickened  with 
flour.  Flavor  with  celery-seeds  or  pieces  of  celery,  which 
are  to  be  strained  out  before  serving.     Salt  to  taste. 

Scrambled  Eggs. 

Take  4  eggs,  1/2  teaspoonful  of  salt,  1  saltspoonful  of 
pepper,  V4  cup  of  milk,  and  1  tablespoonful  of  butter. 


334  INFANT-FEEDING. 

Beat  the  eggs  lightly;  add  the  salt,  pepper,  and  milk. 
Put  the  butter  into  a  saucepan;  when  melted  and  hot, 
add  the  eggs.  Stir  over  hot  water  until  of  a  soft,  creamy 
consistency.     Serve  on  buttered  toast. 

Soft-Boiled  Eggs. 

Drop  2  eggs  into  enough  boiling  water  to  cover  them. 
Let  them  stand  on  the  back  of  stove,  where  the  water  will 
keep  hot,  but  not  boil,  for  eight  minutes.  An  egg  to  be 
properly  cooked  should  never  be  boiled  in  boiling  water, 
as  the  white  hardens  unevenly  before  the  yolk  is  cooked. 
The  yolk  and  white  should  be  of  a  jelly-like  consistency. 

To  Pkedigest  Eggs. 

Break  a  fresh  egg;  after  thoroughly  stirring  add  to 
it  2  grains  of  caroid  powder  and  stir  thoroughly.  The 
yolk  is  at  once  changed  into  a  limpid  liquid  and  soon, 
though  not  so  quickly,  the  albumin  is  completely  dis- 
solved. This  is  done  at  a  temperature  of  from  70°  to 
80°  F. 

Raw  eggs  so  treated  and  slightly  salted  are  not  un- 
pleasant to  the  taste.  They  may  be  added  to  a  soup, 
poured  upon  dry  toast,  or  mixed  with  prepared  rice. 

Pkedigested  Egg-toast. 

Upon  2  pieces  of  toast  pour  2  eggs  previously  digested 
with  caroid  as  above  directed.  Now  place  in  oven  and 
allow  to  remain  about  three  minutes.  When  ready  to  be 
eaten,  hot  milk  may  be  poured  on  the  toast.  The  milk 
cannot  be  mixed  with  the  egg,  or  allowed  to  stand  upon 
the  toast  for  any  length  of  time,  because  the  unspent 
strength  of  the  caroid  present  acting  upon  the  casein  of 
the  milk  will  make  the  entire  dish  bitter.  If  eaten  imme- 
diately, the  milk  will  be  partially  peptonized,  but  it  will 
not  be  bitter. 


DIETARY.  335 

Infant's  Food. 

About  1  teaspoonful  of  gelatin  should  be  dissolved 
by  boiling  in  1/2  pint  of  water.  Toward  the  end  of  the 
boiling  1  gill  of  cows'  milk  and  1  teaspoonful  of  arrow- 
root (made  into  a  paste  with  cold  water)  are  to  be  stirred 
into  the  solution,  and  1  to  2  tablespoonfuls  of  cream 
added  just  at  the  termination  of  the  cooking.  It  is  then 
to  be  moderately  sweetened  with  white  sugar,  when  it  is 
ready  for  use.  The  whole  preparation  should  occupy 
about  fifteen  minutes. 

Custard  Pudding. 

Break  1  egg  into  a  teacup,  and  mix  thoroughly  with 
sugar  to  taste;  then  add  milk  to  nearly  fill  the  cup,  mix 
again,  and  tie  over  the  cup  a  small  piece  of  linen;  place 
the  cup  in  a  shallow  saucepan  half-full  of  water  and  boil 
for  ten  minutes. 

If  it  is  desired  to  make  a  light  batter  pudding,  a  tea- 
spoonful of  flour  should  be  mixed  in  with  the  milk  before 
tying  up  the  cup. 

Corn-flour  Pudding. 

Take  1  pint  of  milk,  and  mix  with  it  2  tablespoonfuls 
of  flour;  flavor  to  taste;  then  boil  the  whole  eight  min- 
utes; allow  it  to  cool  in  a  mold,  and  serve  up  with  or 
without  jam. 

Rice  Pudding. 

Take  1  teacupf ul  of  rice ;  wash,  and  pour  over  it  boil- 
ing water,  and  let  stand  five  minutes;  then  drain  off  the 
water  and  add  a  cupful  of  sugar  to  the  rice,  a  little  nut- 
meg, 2  quarts  of  milk,  and  1  egg.  Bake  slowly  about  two 
hours,  stirring  occasionally  until  the  last  half-hour,  then 
brown. 

Sago  Pudding. 

Same  as  above  recipe,  sago  being  substituted  for  rice. 


336  infant-feeding. 

Snow  Pudding. 

Dissolve  1/2  box  of  gelatin  in  1  pint  of  cold  water; 
when  soft,  add  1  pint  of  boiling  water,  the  grated  rind 
and  juice  of  2  lemons,  and  2  1/2  cupfuls  of  sugar.  Let 
the  gelatinized  water  stand  until  cold  and  beginning  to 
stiffen.  Then  beat  in  the  well-beaten  whites  of  5  eggs. 
Pour  into  a  mold  and  set  on  ice.  Serve  with  custard 
sauce:  1  quart  of  rich  milk,  the  yolks  of  5  eggs,  and  2 
extra  eggs  added,  and  1/2  cupful  of  sugar.  Flavor  with 
vanilla. 

Peptonized  Oysteks. 

Mince  6  large  or  12  small  oysters;  add  to  them,  in 
their  own  liquor,  5  grains  of  extract  of  pancreas  with  15 
grains  of  sodium  bicarbonate  (or  1  Fairchild  peptonizing 
tube).  This  mixture  is  then  brought  to  blood-heat  (98° 
P.),  and  maintained,  with  occasional  stirring,  at  that 
temperature  thirty  minutes,  when  1  pint  of  milk  is  added 
and  the  temperature  kept  up  from  ten  to  twenty  minutes. 
Finally,  the  mass  is  brought  to  the  boiling-point,  strained, 
and  served.  Gelatin  may  be  added,  and  the  mixture 
served  cold  as  a  jelly.  Cooked  tomato,  onion,  celery,  or 
other  flavoring  suited  to  individual  taste  may  be  added  at 
beginning  of  the  artificial  digestion. 

Oystek-stew. 

Take  1  pint  of  oysters,  1  pint  of  milk,  1  teaspoonful 
of  salt,  x/4  cupful  of  water,  1  tablespoonful  of  butter,  and 
1  saltspoonful  of  pepper.  Scald  the  milk.  Wash  the 
oysters  by  adding  the  water,  and  remove  all  shells.  Drain, 
saving  the  liquor.  Put  the  liquor  into  a  stewpan  and  heat 
slowly.  Skim  carefully.  When  clear,  add  the  oysters  and 
cook  slowly  until  the  edges  curl  and  they  are  plump.  Add 
the  hot  milk,  butter,  salt,  and  pepper,  and  serve.  Do  not 
let  the  oysters  boil,  as  that  toughens  them  and  renders 
them  indigestible. 


DIETARY.  337 

Oyster-broth. 

Cut  into  small  pieces  1  pint  of  small  oysters;  put 
them  into  1/2  pint  of  cold  water,  and  let  them  simmer 
gently  for  ten  minutes  over  a  slow  fire.  Skim,  strain,  and 
add  salt  and  pepper. 

Arrowroot  Pudding. 

Add  the  yolks  of  2  eggs  to  the  plain  arrowroot  recipe 
(following),  with  1  teaspoonful  of  powdered  white  sugar; 
mix  well  and  bake  in  a  lightly  buttered  dish  for  ten  or 
fifteen  minutes. 

Arrowroot. 

Mix  1  teaspoonful  of  Bermuda  arrowroot  with  4 
teaspoonfuls  of  cold  milk.  Stir  it  slowly  into  1/2  pint  of 
boiling  milk,  and  let  it  simmer  for  five  minutes.  It  must 
be  stirred  all  the  time,  to  prevent  lumps  and  to  keep  it 
from  burning.  Add  1/2  teaspoonful  of  sugar  and  a  pinch 
of  salt,  and,  if  desired,  1  of  cinnamon.  In  place  of  the 
cinnamon  1/2  teaspoonful  of  brandy  may  be  used  or  a 
dozen  large  raisins  may  be  boiled  in  the  milk.  If  the 
raisins  are  preferred,  they  should  be  stoned  and  the  sugar 
may  be  omitted. 

Oatmeal-gruel. 

Pound  1/2  cup  of  coarse  oatmeal  until  it  is  mealy. 
Put  it  in  a  tumbler,  and  fill  the  tumbler  with  cold  water. 
Stir  well;  let  it  settle;  then  pour  off  the  mealy  water 
into  a  saucepan.  Fill  again  and  pour  off  the  water,  and 
again  repeat  this,  being  careful  each  time  not  to  disturb 
the  sediment  in  the  bottom  of  the  tumbler.  Boil  the 
water  twenty  minutes.  Season  with  salt.  Thin  with  a 
little  cream  or  milk.     Strain  and  serve  hot. 

Chicken-broth. 

Skin  and  chop  up  a  small  chicken  or  half  a  large  fowl; 
put,  bones  and  all, — with  a  blade  of  mace,  a  sprig  of 


338  INFANT-FEEDING. 

parsley,  1  tablespoonful  of  rice,  and  a  crust  of  bread, — in 
a  quart  of  water  and  boil  for  an  hour,  skimming  it  from 
time  to  time.     Strain  through  a  coarse  colander. 


Clam-broth. 

"Wash  thoroughly  6  large  clams  in  the  shell ;  put  them 
into  a  kettle  with  1  cupful  of  water;  bring  to  boil,  and 
keep  it  boiling  one  minute;  the  shells  open,  the  water 
takes  up  the  proper  quantity  of  juice,  and  the  broth  is 
ready  to  pour  off  and  serve  hot.  Add  a  teaspoonful  of 
finely-pulverized  cracker-crumbs,  a  little  butter,  and  salt 
to  taste. 

Rice-water. 

One  ounce  of  well-washed  Carolina  rice.  Macerate 
for  three  hours  at  a  gentle  heat  in  a  quart  of  water,  and 
then  boil  slowly  for  an  hour  and  strain.  It  may  be  sweet- 
ened and  flavored  with  a  little  lemon-peel.  Useful  in 
diarrhoea,  etc.,  when  the  flavoring  is  best  dispensed  with, 
and  a  little  old  cognac  added. 

Barley-water. 

Take  a  tablespoonful  of  pearl  barley,  grind  it  in  a 
coffee-grinder,  or  pound  it  in  an  ordinary  mortar;  add 
1  pint  of  cold  water,  and  allow  it  to  simmer  slowly  for 
about  an  hour.  Strain  and  add  enough  water  to  make 
1  pint. 

Oatmeal-water. 

Take  a  tablespoonful  of  ordinary  oatmeal,  and  add  1 
pint  of  water.  Allow  it  to  simmer  slowly  for  one  hour 
and  strain.  Add  enough  water  to  make  1  pint.  The  same 
directions  apply  to  making  a  household  mixture  of  farina- 
water,  rice-water,  and  sago-water,  using  the  same  propor- 
tions as  above. 


DIETARY.  339 

Arrowroot-  water. 

Add  2  tablespoonfuls  of  arrowroot  to  1  pint  of  water; 
allow  it  to  simmer  for  half  an  hour,  stirring  it  constantly. 

Egg- water. 

This  is  made  by  mixing  thoroughly  the  white  of  1 
egg  with  6  ounces  of  water  and  adding  a  little  salt.  The 
addition  of  a  few  grains  of  sugar  will  make  the  child  take 
it  better,  and  adds  also  a  food-element. 

Such  a  mixture  is  one  of  the  best  foods  we  have  for 
temporarily  feeding  an  infant  with  digestive  disturbances 
when  we  wish  to  stop  temporarily  all  milk-food. 

Artificial  Milk. 

One  ounce  of  suet  cut  up  very  finely,  and  tied  loosely 
in  a  muslin  bag.  Boil  slowly  for  an  hour  in  thin  barley- 
water,  with  1/4  ounce  of  isinglass  and  a  little  sugar  of 
milk,  adding  a  little  water  occasionally  as  it  boils  away. 
Pound  up  12  sweet  almonds,  pour  the  fluid  slowly  on 
them,  and  incorporate  well.     Strain  before  using. 

Milk  Thickened. 

A  great  deal  of  nourishment  can  be  given  in  milk 
by  thickening  it  with  either  wheat-flour,  rice-flour,  isin- 
glass, or  gum  arabic.  The  method  of  doing  so  is  this: 
with 

Wheat-flour.  —  Rub  a  large  spoonful  of  flour  quite 
smooth,  in  a  few  spoonfuls  of  cold  milk.  Then  add  more 
milk  by  degrees  till  you  have  1/2  pint.  Sweeten  and 
flavor  with  a  little  cinnamon,  and  then  boil  up  the  milk, 
stirring  it  all  the  time  to  prevent  its  getting  lumpy. 

Bice-flour  is  done  in  exactly  the  same  way. 

To  thicken  milk  with  isinglass,  boil  1/2  ounce  of  it 
in  a  pint  of  new  milk,  sweetened  and  flavored.  When  boil- 
ing, strain  it  off.  A  little  less  isinglass  will  do,  unless  the 
milk  is  desired  very  thick. 


340  INFANT-FEEDING. 

For  thickening  with  gum  arabic  the  proportions  will 
vary  according  as  the  milk  is  wanted  more  or  less  thick. 
If  powdered  gum  arabic  is  used,  it  is  done  in  the  same 
way  as  flour;  but  if  lumps,  drop  them  into  hot  milk,  until 
it  is  of  the  desired  thickness,  and  then  boil.  There  is 
much  nourishment  in  this  hot,  and  it  is  very  soothing 
where  either  chest  or  stomach  are  in  an  irritable  state. 

Rice-milk. 

Three  tablespoonfuls  of  rice,  1  quart  of  milk;  wash 
the  rice  and  put  into  a  saucepan  with  the  milk;  simmer 
until  the  rice  is  tender,  stirring  now  and  then,  and 
sweeten.  Tapioca,  semolina,  vermicelli,  and  macaroni 
may  be  similarly  treated. 

Humanized  Mile. 

A  pint  of  milk  is  set  aside  until  the  cream  rises,  and 
this  cream  is  skimmed  off  and  kept.  To  the  milk  remain- 
ing is  added  enough  rennet  to  curdle  it.  The  whey  is 
strained  off  the  curd  and  added,  with  the  previously 
separated  cream,  to  a  pint  of  fresh  cows'  milk.  This  is 
known  as  humanized  milk.  In  some  infants  it  will  be 
well  borne  during  the  first  three  months,  and  to  this  can 
be  added  farinaceous  liquid  for  dilution  if  required. 

Pasteurized  Milk. 

This  is  really  partially  sterilized  milk,  and  consists 
of  sterilization  at  a  temperature  of  140°  F.  instead  of 
212°  F.,  this  sterilization  to  be  continued  for  from 
twenty  minutes  to  half  an  hour.  Pasteurized  milk  should 
only  be  used  during  the  twenty-four  hours  following  this 
process.  A  good  apparatus  for  this  purpose  is  the  one 
known  commercially  and  to  physicians  as  Freeman's  pas- 
teurizing apparatus. 


DIETARY.  341 


Peptonized  Milk. 


This  is  milk  in  which  the  proteids  are  changed  to 
peptones,  or,  in  other  words,  digested,  by  the  addition 
and  action  of  pancreatic  ferment.  This  process  may  be 
stopped  when  partially  performed,  giving  a  product  of 
which  the  taste  is  not  objectionable;  or  it  may  be  carried 
on  to  complete  peptonization,  when  the  product  has  a  very 
bitter,  disagreeable  taste. 

Method. — To  peptonize  milk  partially,  add  to  1  pint 
of  fresh  cows'  milk  and  4  ounces  of  water  5  grains  of 
pancreatic  extract  and  15  grains  of  bicarbonate  of  soda. 
Allow  this  to  stand  at  a  temperature  of  105°  to  115°  F. 
for  five  to  twenty  minutes,  then  bring  to  a  boil  to  kill 
the  ferment,  or  stand  on  ice  to  prevent  its  further  action. 
If  the  milk  is  to  be  used  at  once,  neither  of  these  latter 
is  necessary. 

To  peptonize  the  milk  completely,  allow  the  process 
to  continue  for  one  to  two  hours.  After  this  time  the 
addition  of  acid  produces  no  coagulation. 

In  infant-feeding  it  is  better  to  peptonize  a  modified 
than  a  whole  milk.  Peptonized  milk  is  frequently  very 
useful  in  feeding  an  infant  with  feeble  digestive  powers; 
but  it  is  unwise  to  continue  its  use  over  too  long  a  period, 
as  then  the  infant's  stomach,  being  called  on  to  do  no 
work,  becomes  enfeebled  from  disuse,  and  gradually  un- 
able to  perform  its  proper  function. 

Whey. — By  coagulating  1  pint  of  fresh  milk  by  add- 
ing a  teaspoonful  of  essence  of  pepsin,  and  allowing  this 
to  stand,  a  solid  curd  is  formed  swimming  in  a  liquid 
(whey).  This  has  the  following  composition:  Proteids, 
0.86  per  cent.;  fat,  0.32  per  cent.;  sugar,  4.79  per  cent.; 
salts,  0.65  per  cent.;    water,  93.38  per  cent. 

This  at  times  makes  a  very  valuable  food  for  infants 
in  cases  of  gastric  or  intestinal  disorder,  where  the  use  of 
milk  must  for  a  time  be  interdicted.  Babies  like  it,  it  is 
very  easy  of  digestion,  and  does  not  irritate  the  stomach. 
A  little  wine  may  be  added  if  desired. 


342  infant-feeding. 

Scraped  Beef. 

This  is  another  valuable  and  easily  digested  food.  It 
is  prepared  by  scraping  with  a  dull  knife  some  raw  or 
underdone  lean  beef.  A  tablespoonful  of  this  salted  is 
the  amount  usually  given  at  a  feeding. 

Beef-tea  in  Haste. 

Scrape  1  pound  of  lean  beef  into  fibres  on  a  board. 
Place  the  scraped  meat  in  a  delicately  clean  white-lined 
saucepan  and  pour  1/2  pint  of  boiling  water  upon  it. 
Cover  closely  and  set  by  the  side  of  the  fire  for  ten  min- 
utes; strain  into  a  teacup,  place  the  teacup  in  a  basin  of 
ice-cold  water;  then  remove  all  fat  from  the  surface,  pour 
into  a  warm  cup,  warm  this  gently  with  hot  water  or 
otherwise,  and  serve.  This  can  be  ready  in  fifteen  min- 
utes, and  double  the  quantity  of  meat  can  be  used  if 
necessary.  Bread  and  blotting-paper  are  ineffectual  to 
remove  all  the  fat.  A  tomato  makes  excellent  flavoring, 
and  other  flavors  can  be  added  if  desired.  For  children, 
however,  the  simpler  aliments  are  the  better. 

Beef-and-Chicken  Broth. 

One  pound  of  good  lean  beef  and  a  chicken  boned 
should  be  pounded  together  in  a  mortar,  and  a  little  salt 
added,  and  the  whole  placed  in  a  saucepan  with  nearly  3 
pints  of  cold  water.  Stir  over  the  fire  until  it  boils,  then 
boil  half  an  hour,  strain  through  a  coarse  sieve,  and  serve. 

Liebig's  Extract  of  Beef  .  Thickened. 

A  teaspoonful  of  Liebig's  extract  may  be  added  to  a 
pint  of  boiling  barley-water,  with  a  little  salt,  or  to  this 
may  be  again  added  a  teacupful  of  milk,  or,  instead  of 
the  milk,  the  whites  of  2  eggs  beaten  up  with  2  tablespoon- 
fuls  of  milk  may  be  stirred  into  the  Liebig  beef-tea  and 
barley-water  when  cool  enough  to  be  taken.  Too  great 
heat  will  coagulate  the  albumin. 


DIETARY.  343 

Chicken-,  Veal-,  and  Mutton-  broths. 

The  fleshy  part  of  the  knuckle  of  veal;  a  chicken, 
bones  and  all  chopped  up;  or  2  pounds  of  the  scrag  end 
of  neck  of  mutton,  added  to  2  pints  of  water,  with  a  little 
pepper  and  salt,  and  boiled  two  hours  and  strained,  all 
make  excellent  broths.  Pearl  barley,  rice,  or  vermicelli, 
boiled  separately  till  quite  soft,  may  be  added  when  either 
of  the  broths  is  heated  for  use.  All  fat  must  always  be 
carefully  removed  by  skimming  when  cold. 

Beef-juice. 

Expressed  beef-juice  is  obtained  by  slightly  broiling 
a  piece  of  lean  beef,  and  then  squeezing  the  juice  from  it 
by  a  lemon-squeezer.  ■  One  pound  of  steak  yields  2  or  3 
ounces  of  juice.  This  is  flavored  with  salt  and  given  cold 
or  warm.  Do  not  heat  enough  to  coagulate  the  albumin. 
This  is  very  nutritious  and  usually  well  taken.  It  may 
be  given  at  the  rate  of  a  tablespoonful  three  times  a  day. 

Good,  Nutritious  Beee-tea. 

Mince  1  pound  of  good  beef  (from  which  all  skin,  fat, 
etc.,  has  been  carefully  removed)  and  pour  upon  it  in  an 
earthen  jar  1  pint  of  cold  water.  Stir,  and  let  it  stand  for 
one  hour.  Then  place  the  jar  in  a  moderate  oven  for  one 
hour,  or  stand  the  jar  in  a  saucepan  of  water  and  allow 
the  water  to  boil  gently  for  an  hour.  To  be  exact,  the 
heat  to  which  the  beef-tea  is  raised  should  not  exceed 
180°  F.  Strain  through  a  coarse  sieve  and  allow  it  to 
grow  cold.  When  wanted,  remove  every  particle  of  fat 
from  the  top ;  warm  up  as  much  as  may  be  required,  add- 
ing a  little  salt.  Beef-tea  should,  except  in  the  hottest 
weather,  be  made  a  day  before  it  is  wanted. 

Essence  of  Beef  (with  Heat). 

One  pound  of  gravy-beef  free  from  skin  and  fat,  chop 
as  fine  as  mincemeat,  pound  in  a  mortar  with  3  table- 


344  INFANT-FEEDING. 

spoonfuls  of  soft  water,  and  soak  for  two  hours.  Then 
put  in  a  covered  earthen  jar  with  a  little  salt,  cement  the 
edges  of  the  cover  with  pudding  paste,  and  tie  a  piece  of 
cloth  over  the  top.  Place  the  jar  in  a  pot  half-full  of 
boiling  water,  and  keep  the  pot  on  the  fire  for  four  hours, 
simmering.  Strain  off  the  liquid  essence  through  a  coarse 
sieve;  it  will  be  about  5  or  6  ounces  in  quantity.  One 
teaspoonful  frequently,  with  or  without  wine  or  brandy, 
as  may  be  ordered.  A  teaspoonful  of  cream  may  occa- 
sionally be  added  with  advantage  to  4  ounces  of  the 
essence,  or  it  may  be  thickened  with  flour,  arrowroot,  or 
sago. 

Essence  of  Beef  (Another  Way,  Without  Heat). 

Half  a  pound  of  fresh  beef  cut  up  as  finely  as  pos- 
sible; to  this  add  1/2  pint  of  pure,  soft,  cold  water  (rain- 
water is  excellent,  filtered,  if  necessary,  from  the  nature 
of  the  vessels  in  which  collected,  as  iron  tanks,  etc.);  an 
eggspoonful  of  salt,  and  5  drops  of  pure  hydrochloric  acid 
(spirit  of  salt).  Mix  and  stir  well,  and  after  an  hour  filter 
through  a  conical  sieve  without  pressure.  The  fluid  must 
be  returned  into  the  sieve  until  it  runs  through  clear. 
Next,  another  1/2  pint  of  cold,  pure,  soft  water  is  to  be 
poured  on  the  meat  in  the  sieve,  and  this  is  also  to  run 
through  without  pressure.  The  result  will  be  about  3/4 
pint  of  a  red  solution  of  meat  containing  most  of  the 
albumin,  coloring  and  flavoring  matters,  salts,  and  other 
soluble  materials.  Half  a  wineglassful  of  this  may  be 
taken  cold  for  a  child  twelve  years  old;  a  teaspoonful  to 
a  dessert  or  tablespoonful  for  younger  children.  Or  it 
may  be  slightly  warmed  by  standing  in  a  jar  immersed  in 
hot — not  boiling — water.  It  may  be  colored  with  burnt 
sugar,  if  desirable.  This  is  a  veritable  meat-essence,  and 
is  of  use  in  extreme  prostration,  notably  after  burns,  in 
continued  fever,  in  some  cases  of  dyspepsia,  and  in  the 
diarrhoea  of  infants,  as  alluded  to  elsewhere. 


DIETARY.  345 

Fkesh  Pabula. 

These  contain  essentially  the  so-called  antiscorbutic 
element,  and  may  be  given,  not  only  to  provide  this  un- 
known but  necessary  constituent  of  food,  but  also  as 
additional  nutrient  agents.     The  chief  articles  are: — 

Raw  Meat-juice.- — To  prepare  this  take  2  ounces  of 
gravy-beef,  free  from  fat,  and  chop  into  small  pieces ;  add 
to  2  ounces  (4  tablespoonfuls)  of  water  in  a  cup,  and  stand 
in  a  warm  place  for  half  an  hour;  then  squeeze  through 
muslin  to  express  the  juice.  The  temperature  of  the 
meat-juice  must  never  be  above  lukewarm,  or  the  soluble 
albuminoids  will  be  coagulated  and  its  value  destroyed. 
Raw  meat-juice  will  not  keep  for  more  than  10  or  12 
hours,  and  should  be  made  fresh  whenever  wanted. 

Bananas.  —  Fresh  ripe  bananas,  either  grated  or 
sieved,  afford  a  valuable  fruit  food.  It  has  been  found 
that  bananas  with  milk  will  constitute  a  useful  nourishing 
food  for  infants. 

Egg-albumin. — Egg-albumin  is  prepared  for  use  by 
stirring  up  the  white  of  1  new-laid  egg  with  4  ounces  of 
water.  Prepared  thus  and  sweetened,  it  may  take  the 
place,  for  a  time,  of  the  ordinary  milk  diet  in  infantile 
diarrhoea,  after  appropriate  treatment  with  repeated  small 
doses  of  calomel.  Egg-albumin  can  hardly  be  considered 
as  a  substitute  for  raw  meat-juice,  which  contains  only 
about  3  per  cent,  of  albumin  (myosin),  but  which  is  a 
powerful  digestive  stimulant,  owing  to  the  presence  of 
extractives  (creatin,  etc.). 


LIST  OF  BOOKS  CONSULTED. 


Baginsky:    "Diseases  of  Children,"  1902. 

Henoch:    "Diseases  of  Children." 

Biedert :    "Infant-feeding." 

Monti:    "Infant-feeding  and  Dietetics." 

Jacobi:    "Intestinal  Diseases  of  Infancy  and  Childhood." 

Jacobi:    "Therapeutics  of  Infancy  and  Childhood." 

Article  by  T.  M.  Rotch,  in  Jacobi  "Festschrift." 

Hammersten :   "Text-book  of  Physiological  Chemistry." 

Hammersten :    Eichhorst,  "Clinical  Pathology." 

Archiv  fur  Kinderheilkunde  (editor,  Professor  Baginsky). 

Wing:    "Milk  and  its  Products." 

Ellis:    "Diseases  of  Children." 

Tuttle  Gallaudet:    "Diseases  of  Children." 

Keating :    "Encyclopaedia." 

H.  Neumann,  Berlin:    "Ernahrungsweise  und  Infectionskrankheiten 

im  Sauglingsalter." 
W.     Knoepfelmacher,     Vienna:     "Verdauungsruckstande     bei     der 

Emahrung  Mit  Kuhmilch." 
Sternberg:    "Manual  of  Bacteriology." 
Hueppe:    "Principles  of  Bacteriology." 
Pfeiffer:    "Analysis  of  Milk,"  Wiesbaden,  1887. 
Heubner:     "Sauglingsernaehrung  und   Saeuglings-spitaeler,"   Berlin, 

1897. 
Holt:    "Diseases  of  Children." 

R.  Schroter:    "Jahrbuch  fur  Kinderheilkunde,"  1887. 
A.   Wroblewski:     "Beitrage   zur   Kenntnis    des   Frauencaseins,   etc. 

Mittheilungen  aus  den  Kliniken  und  medicinischen  Instituten 

der  Schweiz,"  1894. 
J.  Lehmann:    "Milchuntersuchungen,"  Pfluger's  Archiv,  1894. 
Fr.  Soldner:    "Die  Salze  der  Milch,"  etc.    Inauguration  dissertation, 

Langensalza,  1888. 
Th.  Escherich:.    "Jahrbuch  fur  Kinderheilkunde,"  1891. 
E.  Salkowski  and  M.  Hahn:  Pniiger's  Archiv,  1895. 
H.  Wegscheider:    "Ueber  die  normale  Verdauung  bei  Sauglingen," 

Berlin,  1875. 
O.  Heubner:    "Berliner  klinische  Wochenschrift,  1894. 
J.  Uffelmann:    Pfliiger's  Archiv,  1882. 

(346) 


LIST  OF  BOOKS  CONSULTED.  347 

Biedert:    "Jahrbuch  fur  Kinderheilkunde,"  1881. 

Th.  Escherich:    Miinchener  niedicinische  Wochenschrift,  1889. 

F.  Soxhlet:    Miinchener  medicinische  Wochenschrift,  1893. 

Th.  Escherich:    "Verhandlungen  der  XI  Versamnilung  der  Gesell- 

schaft  fur  Kinderheilkunde,"  1894. 
Gartner:    Ibidem,  1894. 
A.  Jacobi:    in  Gerhardt's  "Handbuch  der  Kinderheilkunde." 


INDEX. 


Absorption    21 

of  carbohydrates  14 

of  fat   10 

Achroodextrin    11 

Acid,  hydrochloric,  the  addition  of,  to  food 72 

lactic,  quantity  of,  in  infant's  stomach 3 

Acidity,  relative.,  of  an  infant's  stomach  2 

Acids  in  the  infant's  stomach 2 

After  weaning,  time  of  feeding   84 

Albumin  and  the  gastric  juice  15 

-water    329 

Albuminose   29 

Albuminous,  or  proteid,  substances \  . .  .     29 

Almond-milk    321 

Amylopsin  11 

Apple-water  329 

Arrowroot 337 

pudding    337 

-water  339 

Athrepsia  infantum   303 

causes  of 305 

feeding  in   305 

stages  of  303 

Bacillus  acidi  lactici   113 

"b,"  summary  of 53 

'd"  of  Booker 44 

1  of  Booker 45 

f"  of  Booker 46 

'  of  Booker 48 

'h"  of  Booker 49 

"k"  of  Booker 49 

'  of  Booker 50 

Backhaus's  milk   221 

Bacteria  of  the  intestine 39 

Bacterium  coli  commune 39 

biological  characters  of 41 

morphology  of  40 

pathogenesis  of  43 

varieties  of  44 

Bacterium  lactis  aerogenes 51 

biological  characters  of 52 

morphology  of  51 

pathogenesis  of   52 

Baked  apples   333 

Bananas  345 

(348) 


INDEX.  349 


PAGE 

Barley-water   330,  338 

Barlow's  disease  from  improper  feeding 183 

Beef -arid-chicken  broth 342 

essence  of 343,  344 

-juice     343 

scraped 342 

-tea   343 

-tea  in  haste 342 

Biedert's  cream,  directions  for  making 146 

cream-mixtures    146 

Bile,  cholesterin  in  18 

glycocholic  acid  in 18 

in  nurslings   18 

lecithin  in   18 

mucin  in   18 

quantity  of : 18 

unorganized  ferments  in 18 

Bottle-brush    188 

-feeding    144 

amount  of  milk  to  be  given  in 144 

general  rules  for 151 

Breast-feeding  67 

rules  for 67 

suggestions  for 68 

time  for 67 

Breast-milk  60 

composition  of 62 

immunity  by    56 

proteids,  method  for  estimation  of 31 

-pump   90 

specimen  of,  for  chemical  examination 64 

Brooder    197 

Buttermilk  feeding  115 

how  to  prepare  for  infants 115 

quality  of  118 

Calf's-foot  jelly   331 

Cane-sugar 139 

Carbohydrates   26 

and  their  formulae 21 

Cellulose    22 

Cereal  milk  211 

composition  of,  when  prepared   211 

Chicken-broth    337 

veal-,  and  mutton-  broths 343 

Chloride  of  sodium  28 

Chocolate    227 

sweetened    339 

unsweetened   330 

Clam-broth    38 

Clinical  illustrations  of  how  to  feed 154 

Cocoa   226 

and  chocolate  cocoa,  how  to  prepare 330 

Coffee,  French   339 


350  INDEX. 


PAGE 

Coffee,  nutrition   331 

Coit's  decimal  method  for  home-modification  of  milk 148 

Colic   271 

causes  of  271 

drug  treatment  of 273 

massage  in   272 

sugar  as  a  cause  of 274 

Colostrum    30,     55 

Condensed  milk  or  cream 224 

quantity  of  sugar  in 224 

Constipation   275 

causes  of 276 

dietetic  treatment  of  284 

drug  treatment  of 280 

electricity  in 283 

exercise  for 284 

hygienic  treatment  of  285 

immediate  relief  of  279 

massage  in   283 

water  for 279 

Corn-flour  pudding 335 

Cow,  the  breed  of  a 127 

Cows,  age  of 128 

tuberculin  reaction  in  Ill 

Cows'  food   110 

Cows'  milk   107 

albuminoids  in 129 

analysis  of   107 

average  percentage  of  fat  in  110 

composition,  variation,  and  production  of  107 

lime-salts  in   33 

properties   of    97 

raw   98 

solutions  for  rendering  alkaline 140 

yellowish  112 

Cream  134 

decimal    148 

eight-per-cent 135 

for  home-modification   134 

how  to  procure   135 

-mixture,  Biedert's   145 

ordinary 134 

to  pasteurize  the 136 

-toast    332 

twelve-per-cent 135 

uses  of  134 

Curds  and  whey 327 

Custard  pudding  335 

Cyanosis  in  premature  infants  198 

Dairy,  the  ideal  133 

Dentition   299 

Dextrose    11 

alcoholic  fermentation  of  12 


INDEX.  351 

PAGE 

Diastasic  action  of  succus  entericus 12 

Diastasis    . .  . 22 

Diet  after  the  period  of  weaning   87 

Dietary 321 

Dietetic  management  of  a  bottle-fed  baby 318 

Dried-milk  foods  206 

Drugs  taken  by  a  nursing  woman,  influence  of  on  baby 69 

Egg-albumin 345 

-toast    332 

-water 339 

Eggnog 331 

Eggs,  scrambled 333 

soft-boiled 334 

to  predigest 334 

Enzymes    22 

Epithelium  and  the  glands,  secretory  and  absorbing  power  of..  16 

Erythrodextrin    11 

Eskay's  albumenized  food   214 

composition  of,  when  prepared 215 

Faeces,  peptonizing  ferment  in 266 

proteids  in 266 

quantity  of 265 

saccharin  ferment  in  266 

Farinaceous  dried-milk  foods   207 

Fat,  absorption  of 27 

diarrhoea    265 

-globules  in  milk   71 

Fats    26 

and  carbohydrates,  value  of 27 

Feeding  children  afflicted  with  cleft  palate  260 

•  forced    195,  250 

dangers  of 196 

in  diphtheria-intubation  cases 254 

infants,  general  rules  for 105 

mixed   69 

nasal   252 

in  diphtheria    257 

modus  operandi  of  252 

quantity  of  food  in 252 

of  infants  in  incubators   194 

method  of   194 

results  of 199 

of  sick  children 72 

rectal,  general  rules  for 258 

in  diphtheria    254 

rules  for    152 

-table  and  cream-mixtures   145 

-bottles    189 

Fermentation  12,  13 

lactic  12 

of  sugar 13 

Ferments  and  their  actions 11 


352  INDEX. 


PAGE 

Ferments,  organized   20 

unorganized,  table  of 19 

Flour-ball  feeding ' 71 

Food,  addition  of  hydrochloric  acid  to 72 

Foods,  additional,  during  the  nursing  period 71 

Freeman's  pasteurizer   180 

Gas  in  the  intestine,  function  of 15 

Gastric  juice,  influence  of,  on  pathogenic  germs 4 

of  infantile  stomach 2 

power  of  transforming  albumin 15 

Gavage 250 

Giaourdi 114 

Glandular  system  of  infants,  development  of 16 

Glucose 12 

Grape-sugar    11 

Gruels,  dextrinized  191 

method  of  dextrinizing  191 

Gum-arabic  water 328 

Hand-feeding 144 

Home  modilier,  materna 166 

Horlick's  malted  milk 209 

composition  of,  when  prepared  209 

Humanized  milk   217 

composition  of,  when  prepared  217 

directions  for   323 

Hydrocarbons 26 

Hydrochloric  acid  in  the  infant's  stomach 2 

Hydrolysis   22 

Hydrolytic  agents 20 

Ice-cream  and  water-ices 227 

Imperial  granum 213 

composition  of,  when  prepared  213 

Incubator  treatment  of  premature  infants,  results  of 199 

-feeding 194 

Incubators,  method  of  feeding  in 194 

Infant- feeding 103 

in  summer  complaint 317 

Infant-foods    206 

as  adjuncts  to  fresh  cows'  milk 206 

Infant-stools 261 

Infants,  general  rules  for  feeding 105 

premature   197 

Infants'  food 335 

saliva   2 

weight 92 

Intestinal  muscles,  action  of 16 

Intestine,  infantile,  formation  of  gas  in 15 

Intestine,  length  of 15 

Junket  327 

of  milk  and  egg 322 


INDEX.  353 


PAGE 


Keller's  malt-soup   231,  321 

Koumiss    114 

Laboratory  modification  of  milk 236 

Lactose    13 

Lahmann's  vegetable-milk    222 

Lemonade   328 

Levulose    13 

Liebig's  extract  of  beef,  thickened 342 

Lime-salts  in  cows'  milk 33 

-water 328 

and  milk 34 

Liver  and  bile  in  nurslings 18 

Long  rubber  tubes 190 

Malassimilation  of  food 303 

Malt-diastase,  action  of 23 

-extracts    193 

Malted  dried-milk  foods   207 

Maltose 11,  12 

Mammary  glands,  the  two 56 

Marasmus   303 

Meat,  raw,  beneficial  effects  of 102 

Mellin's  food 215 

composition  of,  when  prepared 215 

formulae  and  analyses  for  preparing 216 

Men  suckling  children 58 

Microbes  in  the  milk  of  nursing  women 70 

Milk,  addition  of  glycerin  to 140 

sugar  to 139 

aerated 204 

albuminoids  of 64 

and  albumin 329 

artificial 339 

bacteriology  of    125 

bicarbonate  of  soda  in 34 

burettes   31 

certified    204 

changes  in,  by  boiling 171 

by  sterilization 164 

curdling  and  diluents  of 129 

detection  and  addition  of  preservatives  to 122 

directions  for  pasteurizing 179 

effect  of  alkalies  on 128 

of  heating 164 

fat  in 25 

formaldehyde  as  an  addition  to 122 

fresh  raw 100 

frozen  113 

home-modification  of 148 

human,  properties  of  96 

modification  of 136 

of  men's  breasts 59 

pasteurization  of 172 

23 


INDEX. 


PAGE 

Milk,  pasteurized   177,  340 

peptonized 341 

phosphorus  in 64 

proteids  in 31 

raw,  assimilation  of 100 

salicylic  acid  as  an  addition  to 124 

salts  contained  in  131 

Soxhlet's  method  of  sterilizing 174 

sour 113 

sterilized    173 

substitute  for,  in  diseases  of  stomach  and  intestines   ....   106 

sugar  in 25 

-teeth    299 

test  for  salicylic  acid  in 124 

tests  for  formaldehyde  in 122 

thickened 339 

witch's   57 

woman's,  methods  of  changing  the  ingredients  in 78 

idiosyncrasies  in  children  228 

-modifying  gauge    168 

-punch    329 

salty  126 

-sugar 35 

bacteria  in 38 

impurities  in 37 

process  of  making 35 

solutions    138 

-toast 333 

Milkine   210 

Milking,  precautions  necessary  in 127 

Milking  time  and  stage  of 128 

Mother-milk,  Professor  Gaertner  218 

Muscles,  intestinal,  action  of 16 

Mutton-soup 333 

Nathan  Straus  milk-laboratories  and  similar  charities   268 

Nestle's  food 208 

Nipple,  ventilated  187 

-shield 89 

-sterilizer  188 

Nipples  and  bottles 185 

artificial 185 

mode  of  cleansing 185 

management  of  woman's 89 

before  the  baby  is  born 89 

odor  of 188 

recommended    187 

tender 90 

Nursing  centre 2 

mother,  the  diet  of  a 73 

Oatmeal-gruel 337 

-water  338 

Orangeade  329 


INDEX.  355 


PAGE 

Oyster-broth 337 

-stew 336 

Oysters,  peptonized 336 

Partially  peptonized  milk 325 

Pepsin  and  hydrochloric  acid  in  infant's  stomach 3 

Peptogenic  milk-powder    217,  322 

Peptones    29 

Peptonized  milk 325 

milk -gruel   326 

Predigested  beans  324 

peas 324 

eggs  334 

egg-toast   334 

food 324 

how  to  prepare .* 324 

rice    324 

Ptyalin 11 

Putrefaction  20 

Kacahout  powder   318 

Rachitis  288 

causes  of 289 

diet  required  in 291 

external  treatment  of 291 

internal  treatment  of 292 

prevention  of 288 

prognosis  of 291 

Paw  meat-juice  345 

Pectal  alimentation  in  summer  complaint 318 

Rice-milk 340 

-pudding 335 

-water 338 

Saccharated  skim-milk 149 

Sago-pudding   335 

Saliva,  action  of,  on  various  bacteria 4 

secretion  of 2 

Salts   28 

and  water  29 

Schedule  for  feeding  and  formulae ; 153 

Schizomycetes,  intestinal,  diastasie  action  of   12 

Scorbutus 294 

Scurvy 101,  294 

avoidance  of 105 

value  of  milk  in 105 

Scybala,  removal  of 280 

Secretory  and  absorbent  power  of  the  epithelium  and  glands  .  .  16 

Self-weaning  84 

Sick  children,  the  feeding  of 72 

Siphon,  to  clean  the  glass   137 

Snow-pudding 336 

Soft  custard  331 

Starch,  saccharification  of 22 


35G  INDEX. 


PAGE 

Starch,  soluble   22 

Statistics  of  births  and  deaths 286 

Sterility  of  human  milk 70 

Stomach,  acids  in  the 2 

amount  of  secretion  in 2 

capacity 6 

infantile 1 

mucous  membrane  of  the 1 

muscular  fibres  of 1 

ptyalin  in   11 

quantity  of  lactic  acid  in 3 

relative  acidity  of 2 

Stool,  dyspeptic 265 

of  a  nursling   261 

Stools  263 

blood  in - 263 

brown    263,  264 

casein  in   265 

jelly-like  masses  in 264 

long  shreds  of  mucus  in  265 

mucus  in  264 

muddy    264 

reaction  of 262 

typical  green 263 

white  or  light  gray 264 

Succus  entericus,  diastasic  action  of 12 

Sucrose 13 

Sucking  act 2 

centre   2 

Sugar,  contra-indications  to  the  use  of 139 

in  milk 25 

solution,  standard 149 

Summer  complaint  in  a  nursing  infant 320 

Tamarind-water 328 

Tapioca-cream    332 

Tea   329 

Teething 299 

Toast,  dry 332 

-water 329 

Toasted  bread 332 

Top-milk    135 

Tuberculous  diseases  in  children,  causes  of 112 

Tyndallization   183 

Walker-Gordon  laboratory  milk 236 

Wampole's  milk-food 212 

composition  of  when  prepared 212 

Wasting  disease    303 

Water  in  the  feeding  of  infants  142 

quantity  of,  to  be  given  to  infants 142 

Weaning  76 

and  feeding  from  one  year  to  fifteen  months  82 


INDEX.  357 


PAGE 
Weighing  to  determine  the  quantity  of  milk  an  infant  has 

taken 93 

Weight-chart  for  an  infant 95 

Wet-nurse   76 

diet  of  a 77 

manner  of  living  77 

Wet-nursing   79 

Whey 326,  328 

White  celery  soup    333 

Zomotherapy    102 


.^=Le^U~\j 


